Blood Components

And Therapy
Dr.Gunupuru Bharat
Department of Anesthesiology
 Patient blood management (PBM)

“The timely application of evidence-based medical and surgical

concepts designed to maintain hemoglobin concentration,
optimize hemostasis and minimize blood loss in an effort to
improve patient outcome.”

Miller’s Anesthesia 9th edition

 Haemostasis Pathway
Primary haemostasis-
GPiib3a • Initiation

• Propagation

• Stabilization
GPiib3a
Neonatal platelets: mediators of primary
hemostasis in the developing hemostatic
system Kristina M. Haley , Michael Recht
and Owen J.T. McCarty
Coagulation
Cascade
 Blood Storage and Storage lesions

Requirement - at least 70% of

transfused RBCs should remain in
circulation for 24 hours after infusion

Citrate phosphate dextrose adenine-1

(CPDA-1)

Citrate - prevents clotting by binding Ca2+

Phosphate - Buffer
Dextrose - Energy source
Adenine - Prolongs storage

The ABC’s of Blood Components : University of Michigan hospital Miller’s Anesthesia 9th edition
AS-7 - increases storage time to at least 56 days
The pathophysiology and consequences of red blood cell storage
D. Orlov and K. Karkouti
Storage Lesion
 Transfusion 1) Hb
trigger 2) Oxygen Extraction Ratio

Oxygen Extraction Ratio(O2ER) –

• Global oxygen delivery (DO2) - total amount of oxygen delivered to the
tissues per minute, irrespective of the distribution of blood flow
• Oxygen consumption (VO2) - total amount of oxygen removed from the
blood due to tissue oxidative metabolism per minute
• O2ER = VO2 / DO2 = (SaO2-SvO2) / SaO2
• If O2ER >50% - Tissue disoxia – increased lactate

The ICU Book 3rd Edition - Paul L Marino

Whole blood -

Contraindications-
Risk of volume overload in patients with:
Chronic anemia
Incipient cardiac failure
 PRBC - Indication
 Haemoglobin concentration of less than 7 g/dL for stable, adult
inpatients including those in the intensive care unit

 Haemoglobin concentration of less than 8 g/dL for a select group

of post surgery patients or those with pre-existing cardiac disease.

November 15, 2016

 Transfuse within 4 h of removal
from the blood fridge
AABB Red Blood Cell Transfusion
Guidelines
Mark H. Yazer, MD1; Darrell J. Triulzi, MD1
JAMA. 2016;316(19):1984-1985.
doi:10.1001/jama.2016.10887
 Platelets - Indication
 Prevention and treatment of bleeding due to thrombocytopenia or
platelet function defects.

If patient is actively bleeding, transfuse to a platelet count > 75000/uL

Clinical Situation Threshold

Prophylactic use 10000
Prophylactic use with additional risk factor (Sepsis) 10000-20000
Major Surgery / Invasive Procedures 50000
Neuraxial Blockade 50000
Prophylactic use- Closed-compartment Surgery (Eye, Brain) 100000
Klein et al. | AAGBI blood transfusion guidelines 2016
 Platelets

• Platelets do not have to be the same group

• Each pack increase platelet count by approximately 30000
• Commence transfusion within 30 min of removal from incubator
• Bacterial infection transmission- highest (1 in 12,000) because
platelets are stored at 22 °C.
FFP - Indication
Clinical Situation
Major Haemorrhage
Acute disseminated intravascular coagulation (DIC) with bleeding
INR > 1.5 (or POC equivalent) >2(ASA)
Immediate reversal of Warfarin- induced haemorrhage
(PCC is first choice)
Replacement of coagulation factors if specific factors are not available
(uncommon).

Klein et al. | AAGBI blood transfusion guidelines 2016

 Fresh Frozen Plasma

• FFP should be the same group as the patient

• Rapidly frozen to below -25 °C to maintain the integrity of labile
coagulation factors.
• Thawing- dry oven (10 min), microwave (2–3 min), water bath (20 min)
• Thawed FFP can be used for up to 5 days when stored at 4 °C
• Never be refrozen
• Use within 30 min once out of the fridge
• Therapeutic dose -15 ml/kg (Volume per bag is 300 ml)
Cryoprecipitate - Indication
Clinical Situation - Hypofibrinogenemia due to
Major Haemorrhage and Massive transfusion
Disseminated intravascular coagulation (DIC)
Liver and renal failure with bleeding
Bleeding associated with thrombolytic therapy

Klein et al. | AAGBI blood transfusion guidelines 2016

 Cryoprecipitate

• Contains – fibrinogen, factor VIII, von Willebrand factor, factor

XIII and fibronectin
• Stored at -25 °C
• Once thawed- Can be kept at ambient temperature for 4 h
• Do not refrigerate again
• Available as pooled bags of five units - 100–200 ml per bag
Special blood components - Indication
Prothrombin complex Urgent reversal of
concentrate (Factors II, VII, IX warfarin
and X, with protein S, C and
heparin)

Fibrinogen concentrate Congenital hypofibrogenemia

Recombinant factor VIIa Hemophilia
(Increases the risk of
thrombotic complications)

Klein et al. | AAGBI blood transfusion guidelines 2016

 Approach to Patient
• Consent
• History
• Definition of Major Haemorrhage
• Assessing blood loss
• Major haemorrhage protocol
• Case specific management
• Transfusion Reaction
Jehovah’s Witnesses believe that the Bible is
the inspired Word of God, accepting both the
Old and New Testaments

‘Everything that lives, and moves will be food for you. Just as I
gave you the green plants, I now give you everything. But you must
not eat meat that has its lifeblood still in it.’ New International
Bible, Genesis 9:3–4 ‘

. . . because the life of every creature is its blood. That is why I have
said to the Israelites, “You must not eat the blood of any creature,
because the life of every creature is its blood; anyone who eats it
must be cut off.”’ New International Bible, Leviticus 17:14
 History
Review medical records and interview the patient or family to identify:

 Previous blood transfusion

 History of drug-induced coagulopathy
(warfarin, clopidogrel, aspirin, vitamins or herbal supplements)
 Presence of congenital coagulopathy
 History of thrombotic events (deep vein thrombosis, pulmonary
embolism)
 Risk factors for organ ischemia (cardiorespiratory disease)
 Major Haemorrhage - Definition

 Loss of more than one blood volume within 24 h

 > 10 units of pRBCs within the first 24 hours
 50% of total blood volume lost in < 3 h
 More than 4 units in 1 hour
 Bleeding in excess of 150 ml/min.
 Pediatrics – >80ml/kg- 24 hrs., >40ml/Kg- 3hrs, 3ml/kg/min
 Clinically-based definition is bleeding which leads to a systolic
blood pressure of less than 90 mmHg or a heart rate of more
than 110 beats/min in adults
Advanced Trauma Life Support
AAGBI guidelines: the use of blood components and their alternatives 2016 A. A. Klein,1 P. Arnold, Anaesthesia 2016
 Assessment of blood loss
 Subjective assessment by physicians – Convenient, Inaccurate

 Gravimetric analysis-
Weights of surgical sponges are subtracted from the wet weights of
blood-soaked sponges
Conversion to quantify the blood
1 gm weight = 1 mL

 Photometric analysis –
Rinsing and assaying blood-soaked products to determine hemoglobin
concentration through spectrophotometry
Impractical
Visual assessment Allowable blood loss

ABL = EBV X (HCTi -HCTf)

HCTi

Estimated blood volume-

EBV = Weight x Blood volume
 Major Haemorrhage Protocol
Protocol should be defined by the institution
 Most major hemorrhage packs contain four units of RBCs and
four units of FFP. 1:1:1 ratio of RBC–FFP- Platelet transfusion
maintained until the results of hemostatic tests are known.

 Activation should mobilise resources, such as additional (senior)

staff and porter, blood warmers, pressure infusers and cell
salvage devices

 Group O red cells should be readily available and transfused if

hemorrhage is life-threatening
 Initial Resuscitation
 Vascular Access –
• Two large caliber (minimum 18-gauge in an adult) peripheral IV catheters.
 Initial Fluid Resuscitation-
• During uncontrolled hemorrhage, avoid fluids for volume resuscitation
unless there is profound hypotension and no blood available
• ATLS – 1L crystalloids in adults, 20ml/kg for children < 40Kg
• Use rapid infusion pumps
• Use fluid warmers [heat the fluid to 39°C (102.2°F)]
 Draw blood samples for type and crossmatch, CBC, PT, APTT, INR, LFT, RFT
Does not reflect the dynamic clinical situation
 Early administration of tranexamic acid
1 g bolus over 10 mins and an additional infusion of 500 mg/hr
AAGBI guidelines: the use of blood components and their alternatives 2016 A. A. Klein,1 P. Arnold, Anaesthesia 2016
Lethal Triad of Death
During resuscitation
prevent:
Hypothermia
Acidosis
Hypocalcemia
(ionized calcium > 1.0 mmol/l)
Hyperkalemia
 Monitoring – Point of Care testing

Arterial blood Gas

Analysis

HemoCue Spectrophotometric finger

technology (Masimo SpHb)
 Monitoring – Point of Care testing
(Coagulation)
Activated clotting time

Viscoelastic Testing of Coagulation- Clinton P Jones INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 55, Number 3, 96–
108, DOI:10.1097/AIA.0000000000000155
Nomenclature
 Trauma

Critically ill

Obstetric Sx
Clinical Situation
Cardiac Sx
Paediatric
Oncological Sx
 Trauma
Early hemorrhage control – temporary haemostatic devices (pressure
tourniquets), interventional radiological control

Permissive hypotension –
• Balancing the goal of organ perfusion & tissue oxygenation with the
avoidance of rebleeding by accepting a lower-than-normal blood pressure
• Target a systolic pressure of less than 100 mm Hg with MAP between 50 to
60 mm Hg
• Early use of vasopressors should be avoided during active hemorrhage
Transfusion-
• 1:1:1 transfusion protocol
• Initial Damage control resuscitation while active bleeding, and then
laboratory/POC -guided treatment once hemorrhage control is achieved
 Critically ill

Evidence does not support increasing oxygen delivery with RBC

transfusion when Hb is > 7 g/dl unless the patient has cardiac
disease

Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill
patients. British Journal of Haematology 2013; 160: 445–64
 Obstetric Surgery
 Fibrinogen < 200 mg/dL-
Positive predictive value for
severe PPH

Normal plasma fibrinogen

(Pregnancy) - 400–600 mg/dl

 Tranexamic acid

 Early use of FFP

 Cardiac
Surgery
 Elective cardiac surgery should not be undertaken in an anemic patient

 Cardiopulmonary bypass alters platelet function - platelet count > 75000

is necessary after bypass

 Viscoelastic testing is recommended to guide transfusion

 Activated clotting time (ACT) is used whenever heparin is administered

particularly in cardiac and vascular surgery
 Paediatric
 Restrictive approaches to transfusion are appropriate in children older than 3
months of age
 Blood in children should be prescribed in volume
 Cell salvage is useful in children
 Increased risk of Hypothermia and electrolyte dysfunction

RBC - 10 ml/kg; increase Hb by approximately 2 g/dl.

Cryoprecipitate - 5–10 ml/kg
Platelets- 10–20 ml/kg
Fresh frozen plasma- 10–15 ml/kg
Tranexamic acid - Loading dose of 15 mg/kg followed by infusion 2 mg/kg/hr

Royal College of Paediatrics and Child Health. Major trauma and the use of tranexamic acid in children, 2012
 Onco-Surgery
 Predominant hypercoagulable state
 Dilutional coagulopathy with or without consumptive coagulation -
extensive (tissue trauma) surgery, excessive volume replacement,
hypothermia, hypotension, or acidemia
 Transfusion can make patients sicker

TRIM
Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know? Juan P. Cata and
Vijaya Gottumukkala International Scholarly Research Network ISRN Anesthesiology Volume 2012 doi:10.5402/2012/918938
Transfusion Reaction – Acute
 TRANSFUSION RELATED ACUTE LUNG INJURY
Mechanism-
 Immune
Antibodies in the plasma of donor blood against human leucocyte antigens
(HLA) and human neutrophil alloantigen (HNA) in the recipient
 Non-Immune
Reactive lipid products released from the membranes of the donor blood
cells act as the trigger

Target cell are neutrophil granulocyte - Cells migrate to the lungs - trapped in
the pulmonary microvasculature- Oxygen free radicals and proteolytic enzymes
are released which destroy the endothelial cells of the lung capillaries
Transfusion Reaction – Delayed
Transfusion Reaction – Nonimmunologic Complications
 Autologous Transfusion
Components -
1) Preoperative autologous donation (PAD)
2) Acute normovolemic hemodilution (ANH)
3) Intraoperative and postoperative blood salvage
Preoperative autologous donation
 Donor’s Hb > 11 g/dL prior to donation.
 Repeated donations should be separated by a week
 72 hours between last donation & surgery
AABB Red Blood Cell Transfusion Guidelines Mark H. Yazer, MD1; Darrell J. Triulzi, MD1 JAMA. 2016;316(19):1984-1985.
doi:10.1001/jama.2016.10887
 Acute Normovolemic Haemodilution
(ANH)
1. Whole blood is removed - simultaneously restoring intravascular volume -
crystalloid (3 : 1) or colloid (1 :1)

2. Blood is collected in standard blood bags - citrate anticoagulant

3. Maintained at room temperature < 8 hours or at 4°C for 24 hours

4. Sequestered blood is reinfused into the patient in the reverse order of

collection

Miller’s Anesthesiology 9th edition

CELL
SALVAGE
 References
Miller’s Anesthesia 9th edition

AABB Red Blood Cell Transfusion Guidelines Mark H. Yazer, MD1; Darrell J. Triulzi, MD1 JAMA. 2016;316(19):1984-1985.
doi:10.1001/jama.2016.10887

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and
Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial. JAMA. 2015;313(5):471–482.
doi:10.1001/jama.2015.12

AAGBI guidelines: the use of blood components and their alternatives 2016 A. A. Klein,1 P. Arnold, Anaesthesia 2016, 71,
829–842 doi:10.1111/anae.13489

Retter A, Wyncoll D, Pearse R, et al. Guidelines on the management of anaemia and red cell transfusion in adult critically ill
patients. British Journal of Haematology 2013; 160: 445–64

Advanced trauma life support guidelines 10th edition

The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death,
vascular occlusive events and transfusion requirement in bleeding trauma patients. Roberts I, Shakur H, Coats T, et al.
Health Technol Assess Rep. 2013;17:1–79.
Thank You