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Department of Anesthesiology & Reanimation School of Medicine, MalahayatiUniversity/ Dr. Abdul Moeloek Hospital Bandar Lampung
Introduction
Blood transfusion : Transfer of Blood/ Blood component from donors blood to receivers circulation Goals : - Improve circulation volume - Improve Hb level - Improve coagulation mechanism Cautions : - Appropriate indications - Appropriate techniques - Observations of sign of complications - Prevention and therapy for complications
1. Whole Blood
* Fresh Blood, storing time 4-6 hours advantages : - complete caogulation factors - good blood cell functions disanvantages : - impractical supply - risk of infections transmission i.e lues, CMV
* New blood, storing time 3-4 days advantages : - easy suppliyng disadvantages : - coagulation factors, especially factor V and VIII almost depleted ( high Hb affinity to O2 decreased O2 release from Hb to tissue) + - High concentration of K , amonium and lactic acid
Packed Red Cell - made by separating/extracting plasma in close methode until hematocrit level 70 80 % Red Cell Suspensions - made by mixing RBCs concentrate with solvent on equal volume Washed Red Cell - made by washing RBC concentrate 2-3 times with physiologic NaCl solution : a. PNH (Paroxysmal Nocturnal Hb-uria) b. Acquired Haemolytic Anemia c. Exchange transfusion d. Transfusion on renal transplant.
3. Thrombocyt
given to patients with thrombocyt deficits due to primary disease or secondary due to bleeding. Type of thrombocyt : 1. Platelet Rich Plasma (PRP) PRP made by separating plasma from fresh blood 2. Platelets Concentrate Made by centrifuging PRP and separating its thrombocyt concentrate Storing : a. In 40 Celcius - good haemostatic, short life span b. In 180 Celcius - poor hemostatic, better life span Storing time 48 72 hours
4. Plasma
a. restore blood volume and circulation b. replace and enhance blood proteins c. replace and improve spesific plasma factor * Liquid plasma made by separating plasma from whole blood on packed red cell preparation process * Dry plasma made by drying liquid plasma Advantages : - long storing time (3 years) - easy transport - room temperature storage - no risk of lues infections - independent of blood group Disadvantages : - higher risk of hepatitis infection due to collected from various donors.
* Fresh Frozen Plasma made by separating plasma from fresh whole blood and immediately freezed at minus 600 Celcius (CO2 ice) storage : - at temp. minus 300 C for 1 year - at temp. minus 200 C for 6 months ideally given on : - bleeding cases - as fresh whole bood replacement if mixed with packed red cell
* Cryoprecipitate
made by freezing fresh frozen plasma at minus 600 C and liquified at 4-6 C advantages : contains much amount of factor VIII and factor I (fibrinogen). A bag of cryoprecipitate contains 130 units of Anti Hemophylic Factor (AHF)
Complications of Transfusion
1. Hemolytic Reaction Red blood cell destructions occur producing free Hb in plasma due to blood group incompatibility. If free Hb level more than 25 %, Hb uria occur. Acute : -occur immediately when transfusion. 50 cc of incompatible blood enough to precipitate the reactions
sign : - hot sensation along the veins - specific lumbal pain - depressed chest feeling, dyspneu - headache, flushing face - raised body temp., nausea & vomitting - during anesthesia : tachypneu, hypotension, small pulse pressure, shock. Diffuse bleeding from operative wound. Laboratory : - Hb-uria - Peripheral blood preparate hemolytic sign - Blood bilirubine - Free Hb in plasma - methemoglobine
Delayed : Occur on patients who recieved frequent transfusion or women who previously had delivered baby. Reactions occur after several hours or days after transfusion and commonly after transfusion of second bag or more.
Therapy : stop transfusion, change transfusion set treat shock shock position plasma expander infusion vasopressor sodium bicarbonate oxygenation lasix / 20 % manitol corticosteroids report to blood bank * send back transfused blood * send sample of patients blood * patients urine - control Hb level * thrombocyt * fibrinogen - give compatible fresh blood
2. Non Hemolytic Reactions 1. Allergy - antigen in donors blood will bound with its antibody in recipients serum - antibody which present in donors blood which passively transfered by transfusion to recipient therapy : give antihistamine and corticosteroid on severe reactions.
2. Pyrogen reactions
sign : - febrile (38-400 C) - shivering, headache, pain on the whole body, restless untill convulsions
Sign : - febrile, headache, shivering, vomitting, stomachache, diarrhea to shock. These sign occur during or immediately after transfusion Therapy : - stop transfusion - treat shock (plasma expander, vasopressor, oxygen etc)
4. Overload
occur due to transfusion of relatively too high volume in a short period. For these reason, whole blood should be given cautiously on some circumstances : - anemia - decreased cardiac reserve - renal disease - oedema
sign : - headache, precardial pain, coughing, dyspneu, heavy feeling on both arms, pulmonary rhales and elevated neck veins therapy : For patients with overloading tendency : - Infusion drips as slow as possible (adult 12-30 drips/min, children 6-8 drips/min) - diuretics before transfusion - only blood component is given - close observation during transfusion
6. Acidosis
On patients with acidosis tendency (i.e. renal failure, ileus, septic conditions) administering stored blood will worsening those condition, so did massive transfusion. Therapy : -correction of acidosis with sodium bicarbonate
7. Kalium toxicity
due to elevated K+ level in blood which stored more than 10 days sign: - ECG changes - Cardiac arrest danger Prevention : - administer fresh blood therapy : - enforce diuresis - Glucose 5 % infusion + regular insuline 8-12 units
8. Citrate toxicity
especially on massive transfusion (>2 liters) on patients with poor hepatic function, where citrate will bound to Ca++ ion. Sign : - tetany, tremor, ECG disturbances to cardiac arrest therapy : - Ca gluconate i.v or CaCl2 1 gram every 1000 ml of blood transfused
9. Coagulation disorder
especially on massive transfusion with stored blood, due to reduced thrombocyt and other coagulation factors. Therapy : - administering 1 unit of FFP or cryoprecipitate for every 5 unit of whole blood.
10. Hyperammonium
- amonium blood level increase after 5-7 days and reach maximal level after 3 weeks of storage therapy : - administering fresh blood.
* Malaria sign appear after 1-10 days afer transfusion prevention : Donor is not accepted under 2 years from last attack. therapy : - antimalarial drugs * Syphylis sign appear 9-10 weeks post transfusion and manifest as stage II skin lesions.
Transfusion techniques
1. Infusion set preparation Infus set must be equipped with filter Infusion needle gauge should be appropriate to intended rate of transfusion a. easily damage venous wall, causing swollen tissue b. commonly use on babies,easy fixation c. plastic catheter with stylet inside, if already inserted, will not damage the vein easily
4. On transfusing blood
a. Note! Blood pressure, heart rate, respiration and patinets temperature b. Before transfusing blood, give NaCl infusion c. If blood drips stagnant, change transfusion set d. During first 15 minutes, patients should be carefully monitored e. During transfusion, blood pressure & respiration must be monitored
5. Rate of transfusion
a. On massive bleeding, administer blood as fast as possible (1500 ml in 15 minutes) b. On normovolemic patients : adult : 500 ml / 5-6 hours children : depend on body weight and age