Guidelines for rational use of blood

GUIDELINES FOR RATIONAL USE OF
BLOOD
Dr. Guvera Vasireddy
Department of Pathology
Osmania Medical College
departmentofpathology,osmanamedical
college,Hyderabad
1

THEFIRSTBLOODBANKINMOSCOW
The first
academic
institution
devoted to
the science
of blood
transfusion
was
founded by
Alexander
Bogdanov
in Moscow
in 1925.
2
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―WARS WERE MOTIVATED BY PROFITS, NOT
PRINCIPLES‖
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3
 Henry Norman Bethune
(March 4, 1890 – November
12, 1939;) was a Canadian
physician and medical
innovator.
 Known for his service in war
time medical units during
the Spanish Civil War and
with the Communist Eighth
Route Army (Ba Lu Jun)
during the Second Sino-
Japanese War.
 He developed the first
mobile blood-transfusion
service in Spain in 1936

MAJOR MILESTONES IN BLOOD TRANSFUSION
 Soviet experience travels to America, in 1937 Bernard
Fantus, director of therapeutics at the Cook County Hospital in
Chicago, established the first hospital blood bank in the United
States.
 In 1947, the American Association of Blood Banks, now known as
the AABB, was formed.
 In 1953, the plastic blood bag was invented by the Fenwal Co.,
 By 1962, America's Blood Centres network was established with the
help of hospitals, doctors, local civic groups and community-based
blood centres.
 By 1970, blood banks were using a volunteer donating system;
approximately 5 to 6 million units of blood per year were being
collected.
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AIDS: A NEW DEADLY DISEASE ARRIVES
 Young gay men in the United States started dying from a
mysterious disease in the late 70s and 80s.
 1981 January, Michael S. Gottlieb, MD, a young assistant
professor of medicine at the University of California at Los
Angeles School of Medicine, met Michael — the man who
would become the AIDS index case.
 1982, July 27, The term AIDS (acquired immune deficiency
syndrome) is proposed at a meeting in Washington of gay-
community leaders, federal bureaucrats and the CDC to
replace GRID (gay-related immune deficiency) as evidence
showed it was not gay specific.
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THE DEADLY VIRUS GETS A NAME
 1983, January, Françoise Barré-Sinoussi, at the Pasteur
Institute in Paris, isolates a retrovirus that kills T-cells from
the lymph system of a gay AIDS patient.
 1984, March 4 edition of the MMWR, CDC notes that most
cases of AIDS have been reported among homosexual men
with multiple sexual partners, injection drug
users, Haitians, and hemophiliacs.
 The report suggests that AIDS may be caused by an
infectious agent that is transmitted sexually or through
exposure to blood or blood products and issues
recommendations for preventing transmission.
 This retrovirus would be called by several names, including
LAV and HTLV-III before being named HIV in 1986. 6
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SCREENING FOR HIV MADE MANDATORY
o 1985, March 2, FDA approves the first AIDS antibody
screening tests for use on all donated blood and
plasma intended for transfusion and product
manufacture.
o In addition to HIV several other pathogens have been
made part of routine screening programs in blood
banks world wide.
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WHY DO WE NEED TO BE WARY OF TRANSFUSING
BLOOD AND BLOOD PRODUCTS?
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BLOOD TRANSFUSION RISKS
 Despite rigorous screening blood components
continue to pose a small risk of transmission of
pathogens, including viruses, bacteria, and
parasites.
 Currently unrecognized pathogens may also
emerge in time.
 Some studies have suggested that allogeneic blood
may have an immunomodulatory effect.
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INFECTIOUS DISEASE RISKS
Primary Risks
 Bacteria
 Hepatitis B virus
 Hepatitis C virus
 HIV-1
 HIV-2
 Malaria (primarily
Plasmodium malariae
and P. falciparum)
 Syphilis (Treponema
pallidum)
Additional Risks in
Immunocompromised
Recipients
 Cytomegalovirus
 Parvovirus B19
 Epstein-Barr virus
 Babesiosis (Babesia
microti)
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RARE RISKS
 Chagas disease
(Trypanosoma cruzi)
 West Nile virus
 Hepatitis A
 Variant Creutzfeldt-
Jakob disease
 Human T-cell
lymphotropic viruses
 Leishmaniasis (visceral
Leishmania tropica and
possibly L. donovani)
 Human anaplasmosis
(formerly human
granulocytic
anaplasmosis and
human granulocytic
ehrlichiosis)
 Dengue fever
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THEORETICAL, BUT UNREPORTED RISKS
 Creutzfeldt-Jakob disease
 Human ehrlichiosis (formerly human monocytic
ehrlichiosis)
 Lyme disease (Borrelia burgdorferi)
 Toxoplasmosis (Toxoplasma gondii)
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ESTIMATED RESIDUAL RISKS OF SOME
TRANSFUSION-TRANSMISSIBLE VIRUSES
Virus Recent Risk Estimate Ranges
HIV-1 1/1,467,000 units
HCV 1/1,149,000 units
HBV 1/280,000 – 1/357,000 units
HTLV 1/1,208,000 units
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NON-INFECTIOUS COMPLICATIONS OF
TRANSFUSION
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IMMUNOLOGIC COMPLICATIONS, IMMEDIATE
 Hemolytic transfusion reaction
 Immune-mediated platelet destruction.
 Febrile nonhemolytic reaction.
 Allergic reactions as mild or self-limiting urticaria or
wheezing.
 Anaphylactoid/anaphylactic reactions.
 Transfusion-related acute lung injury (TRALI).
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IMMUNOLOGIC COMPLICATIONS, DELAYED
 Delayed hemolytic reactions occur in previously red-cell-
alloimmunized patients in whom antigens on transfused red
cells provoke anamnestic production of antibody.
 Alloimmunization to antigens of red cells, white cells,
platelets, or plasma proteins may occur unpredictably after
transfusion.
 Post transfusion purpura (PTP) is characterized by the
development of dramatic, sudden, and self limited
thrombocytopenia.
 Transfusion-associated graft-vs.-host disease (TA-GVHD). 17
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METABOLIC AND PHYSIOLOGIC COMPLICATIONS
 Citrate ―toxicity‖ reflects a depression of ionized calcium
caused by the large quantities of citrate anticoagulant.
 Because citrate is promptly metabolized by the liver, this
complication is rare.
 Acidosis or alkalosis and hyper- or hypokalemia
 Transfusion Associated Circulatory Overload can accompany
transfusion of any component at a rate more rapid than the
recipient‘s cardiac output can accommodate.
 Iron overload is a long-term complication of repeated RBC
transfusions
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HOW TO PREVENT TRANSFUSION RELATED
INFECTIONS AND ADVERSE REACTIONS?
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HAEMOVIGILANCE
 "Haemovigilance is required to identify and prevent
occurrence or recurrence of transfusion related
unwanted events, to increase the safety, efficacy and
efficiency of blood transfusion, covering all activities of
the transfusion chain from donor to recipient."
otherwise
 '… A set of surveillance procedures covering the whole
transfusion chain (from the collection of blood and its
components to the follow-up of recipients), intended to
collect and assess information on unexpected or
undesirable effects resulting from the therapeutic use of
labile blood products, and to prevent their occurrence or
recurrence …' 20
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TRANSFUSON RELATED ISSUES IN
SURGICAL PATIENTS
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ENSURE APPROPRIATENESS OF BLOOD
TRANSFUSION
 Risk should be outweighed by the potential
benefits.
 Alternative strategies to reduce the use of
allogeneic blood should be considered.
 Patients should be informed that transfusion is part
of the planned intervention
 The patient‘s consent should be obtained for the
planned transfusion and recorded in the patient‘s
medical chart. 22
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REDUCE EXPOSURE TO ALLOGENEIC TRANSFUSION
 Autologous transfusion
 Surgical, anaesthetic and pharmacological
approaches to reduce blood loss.
 Strategies for management of transfusion
requirements in surgical patients:
1. Pre-operative
2. Intra-operative
3. Post-operative
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PRE-OPERATIVE MANAGEMENT
 Treatment of Pre-existing Anaemia
 Predeposit Autologous Donation
 Avoidance of Drugs that Increase Surgical Blood
loss.
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PATIENTS ANTICOAGULATED WITH WARFARIN 1
ELECTIVE SURGERY
 Stop warfarin 3 days pre-operatively and monitor INR
daily
 Give heparin by infusion or subcutaneously, if required.
 Stop heparin 6 hours pre-operatively.
 Check INR and APTT ratio immediately prior to surgery.
 Commence surgery if INR and APTT ratio are < 2.0.
 Restart warfarin as soon as possible post-operatively.
 Restart heparin at the same time and continue until INR
is in the therapeutic range.
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PATIENTS ANTICOAGULATED WITH
WARFARIN 2
 EMERGENCY SURGERY
 Give vitamin K, 0.5-2.0 mg by slow IV infusion.
 Give fresh frozen plasma, 15 ml/kg. This dose may
need to be repeated to bring coagulation factors to
an acceptable range.
 Check INR immediately prior to surgery.
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PATIENTS ANTICOAGULATED WITH HEPARIN
ELECTIVE SURGERY
 Stop heparin 6 hours pre-operatively.
 Check APTT ratio immediately prior to surgery.
 Restart heparin as soon as appropriate post-operatively.
EMERGENCY SURGERY
 Consider reversal with IV protamine sulphate. 1 mg of
protamine neutralizes 100 iu heparin.
PATIENTS RECEIVING LOW-DOSE HEPARIN
 It is rarely necessary to stop low-dose heparin injections,
used in the prevention of deep vein thrombosis and
pulmonary embolism, prior to surgery.
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INTRA-OPERATIVE MANAGEMENT
 Management of Blood Loss
 Management of Volume Replacement
 Reduction of Oxygen Demand
 Intra-operative Blood Salvage (IBS)
 Antifibrinolytic Agents
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POST-OPERATIVE MANAGEMENT
 Post-operative Blood Salvage (PBS)
 Management of Volume Replacement & On-going
Blood Loss
 Post-operative patients in ICU/HDU require close
monitoring of haemodynamic
status, oxygenation, pain relief, biochemical and
haematological indices and on going blood loss.
 Red Cell Transfusion 30
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THRESHOLDS FOR SPECIFIC SITUATIONS
 Hb <7-10g/dL during surgery associated with major
blood loss or if evidence of impaired oxygen
transport
 Hb <8g/dL; patients on a chronic transfusion
regimen or during marrow suppressive therapy (for
symptom control and appropriate growth)
 Hb <10g/dL; only for very select populations (eg.
neonates)
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RECOMMENDATIONS BY AAAB
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 In hospitalized, hemodynamically stable patients, at what
hemoglobin concentration should a decision to transfuse RBCs
be considered?
 The AABB recommends adhering to a restrictive transfusion
strategy.
 In adult and pediatric intensive care unit patients, transfusion
should be considered at hemoglobin concentrations of 7 g/dL or
less.
 In postoperative surgical patients, transfusion should be
considered at a hemoglobin concentration of 8 g/dL or less or for
symptoms
 Quality of evidence: high; strength of recommendation: strong.

 In hospitalized, hemodynamically stable patients with
preexisting cardiovascular disease, at what hemoglobin
concentration should a decision to transfuse RBCs be
considered?
 The AABB suggests adhering to a restrictive transfusion
strategy. Transfusion should be considered at a
hemoglobin concentration of 8 g/dL or less or for
symptoms.
 Quality of evidence: moderate; strength of
recommendation: weak.
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 In hospitalized, hemodynamically stable patients with
the acute coronary syndrome, at what hemoglobin
concentration should an RBC transfusion be
considered?
 The AABB cannot recommend for or against a liberal or
restrictive RBC transfusion threshold.
 Further research is needed to determine the optimal
threshold.
 Quality of evidence: very low; strength of
recommendation: uncertain.
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 In hospitalized, hemodynamically stable patients, should
transfusion be guided by symptoms rather than
hemoglobin concentration?
 The AABB suggests that transfusion decisions be
influenced by symptoms as well as hemoglobin
concentration.
 Quality of evidence: low; strength of recommendation:
weak.
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BLOOD MANAGEMENT –
GETTING THE RIGHT BLOOD TO THE
RIGHT PATIENT AT THE RIGHT TIME
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HOSPITAL TRANSFUSION COMMITTEE
 Every hospital should establish a hospital
transfusion committee to monitor clinical blood use
and investigate any acute and delayed transfusion
reactions.
 Committee should include medical and surgical
departments along with blood bank director.
 The committee should ensure that National
guidelines on the clinical use of blood are followed.
 If no national guidelines exist, each hospital should
develop local guidelines
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COMMITTEE SHOULD ENSURE THAT THE
FOLLOWING ARE IN PLACE
1. A blood request form.
2. A blood ordering schedule for common surgical
procedures.
3. Guidelines on clinical and laboratory indications
for the use of blood, blood products and simple
alternatives to transfusion
4. Medical devices to minimize the need for
transfusion.
5. Standard operating procedures for each stage in
the clinical transfusion process.
6. The training of all staff involved in the transfusion
process to follow standard operating procedures. 40
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STANDARD OPERATING PROCEDURES FOR
TRANSFUSION PROCESS
1. Ordering blood and blood products for elective/planned
surgery
2. Ordering blood and blood products in an emergency
3. Completing the blood request form
4. Taking and labelling the pre-transfusion blood sample
5. Collecting blood and blood products from the blood bank
6. Storing and transporting blood and blood products, including
storage in the clinical area
7. Administering blood and blood products, including the final
patient identity check
8. Recording transfusions in patient records
9. Monitoring the patient before, during and after transfusion
10. Managing, investigating and recording transfusion reactions.
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ESTABLISHING MAXIMUM SURGICAL BLOOD
ORDERING SCHEDULE
 A table of surgical procedures which lists the
number of units of blood routinely requested, and
cross-matched for them pre-operatively.
 The schedule is based on retrospective analysis of
actual blood usage associated with the individual
surgical procedure.
 However when antibody screen is positive,
compatible blood must be made available in all
cases before surgery.
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DEVELOPING MSBOS
 Data on blood request for all procedures for 6 months is
analysed.
 For each procedure, indicate the number of units cross-
matched and the number of units transfused.
 Calculate the percentage of blood usage:
 In procedures where blood usage is less than 30%, GSH are
performed.
 Other procedures are allotted based on the average number
of blood transfused.
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IMPLEMENTATION OF MSBOS
 MSBOS should be explained to all doctors in the
hospitals and the best way is through the Transfusion
Committee.
 When all heads of department have agreed on a
schedule, it should be circulated and implemented.
 Regular monitoring is necessary to detect any problems
and for ‗fine tuning‘ of the schedule if necessary.
 Confidence in the operation of MSBOS and compliance
by users depend on the laboratory being able to provide
compatible blood whenever it is required, including
urgent requests.
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PROTOCOL FOR GSH GROUP
1. Serum saved for cross-matching must be accurately labelled
and readily accessible.
2. Procedures must be clearly defined to enable blood
transfusion staff to provide compatible blood safely should an
emergency occur during a GSH operation.
3. Communication between the operating theatre and the blood
transfusion laboratory must be clearly defined.
4. Transporting blood between the laboratory and the operating
theatre must have an established priority.
5. For GSH category, the serum is kept for 48 hours. 47
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PROCEDURE FOR EMERGENCIES
 Blood samples from all patients must have a full ABO
and RhD grouping and antibody screening done.
 If required urgently, blood of the same ABO and RhD
can be given after an appropriate ‗quick blood
method‘.
 After been issued, the laboratory would continue to
do a full cross-match.
 If any incompatibility is detected, the patient‘s doctor
must be informed immediately.
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RECOMMENDATIONS IN RH D NEGATIVE PATIENTS
 All Rh D negative patients must receive D negative
whole blood or packed red cells except in certain
situations.
 All blood banks should have a few RhD negative units in
their stock based on their requirement.
 Blood banks to keep a list of their RhD negative donors
who can be contacted in an emergency.
 When D negative blood is not available, the treating
clinicians may decide to allow RhD positive blood to be
given instead. 49
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INSTRUCTIONS FOR USE
 All blood and blood components must be stored under
appropriate conditions as described in the AABB Standards.
 The intended recipient and the blood container must be
properly identified before the transfusion is started.
 Aseptic technique must be employed during preparation and
administration.
 All blood components must be transfused through a filter
designed to remove clots and aggregates (generally a
standard 170- to 260-micron filter).
 Blood and blood components should be mixed thoroughly
before use.
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PRECAUTIONS DURING TRANSFUSION
 No medications should be added to or infused
through the same tubing with blood.
 Lactated Ringer‘s, Injection (USP) or other
solutions containing calcium should never be
added.
 Blood components should be warmed if clinically
indicated.
 Unless otherwise indicated by the patient‘s clinical
condition, the rate of infusion should initially be
slow.
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SPECIAL SITUATIONS
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MANAGEMENT OF ANEMIA IN CANCER PATIENTS
 Cancer-related anemia adversely affects quality of life
and is associated with reduced overall survival.
 Thecorrection of anemia in cancer patients has the
potential to improve treatment efficacy and increase
survival.
 Treatment of anemia in cancer patients using
erythropoiesis-stimulating agents (ESAs) significantly
increases hemoglobin levels.
 Decreases transfusion requirements and improves quality
of life, predominantly by reducing fatigue.
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GRADING OF ANEMIA ACCORDING TO THE
NATIONAL CANCER INSTITUTE
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ERYTHROPOIESIS-STIMULATING AGENTS
 ESAs are capable of increasing hemoglobin levels in
most anemic patients with cancer.
 ESAs increase the risk of thromboembolic events.
 During chemotherapy, ESA treatment should be initiated
when hemoglobin values are lower than 10 g/dl.
 ESAs should not be used in patients with cancer who are
not receiving chemotherapy.
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IRON
 Chemotherapy is associated with abnormal iron
metabolism.
 Another mechanism contributing to iron deficiency in cancer
patients is the low bioavailability of orally administered iron.
 The use of intravenous iron (and not oral iron) during
treatment with ESAs may improve hemoglobin levels even
in the absence of depleted iron stores (or absolute iron
deficiency).
 Recommendations for the optimal supplementation with
ESA treatment in cancer-related anemia need to be
established. 57
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BLOOD TRANSFUSION
 Blood transfusion is capable of immediately correcting
the signs or symptoms resulting from anemia.
 There is wide variation in the levels of hemoglobin that
are used to justify blood transfusions among the various
studies and among different types of cancers.
 There are several acute hazards related to blood
transfusion, and long-term side effects have not been
properly studied.
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SHELF LIFE OF IRRADIATED RED CELLS
 Irradiation of blood products is undertaken using a
dedicated blood irradiator with a long half-life gamma
emitting source.
 Irradiation of red blood cells and whole blood results in
reduced post transfusion red cell recovery and
increases the rate of efflux of intracellular potassium.
 Packs irradiated within 14 days of collection expire 28
days after collection.
 Packs irradiated more than 14 days after collection
expire either 5 days after irradiation OR at original expiry
of pack, whichever comes first.
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SHELF LIFE OF IRRADIATED COMPONENTS
 In patients where hyperkalaemia is a concern, red cells
should be transfused within 24 hours of irradiation.
 Irradiation of platelets has not been shown to cause any
clinically significant change in platelet function.
 Platelets may be irradiated at any stage during their 5
day storage life.
 Granulocytes should be transfused as soon as possible
after collection and irradiation.
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IRRADIATED BLOOD COMPONENTS IN INFANTS
 Irradiation of cellular blood components with a minimum
of 2,500 rad (25 Gy) is recommended for the following:
 infants < 1500 g birth weight
 infants with known or suspected congenital
immunodeficiency syndromes involving T-cells, eg:
DiGeorge syndrome
 infants receiving granulocyte transfusions
 infants receiving directed donor blood components from
blood relatives
 infants undergoing immunosuppressive therapy or
chemotherapy
 Infants receiving exchange transfusions
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CYTOMEGALOVIRUS (CMV)
 Blood components from CMV-seropositive donors
may contain residual leucocytes which are
potentially infectious to seronegative infants.
 CMV-seronegative or leucoreduced cellular
components (RBCs, platelets, granulocytes) should
be provided for infants who weigh <1,200 g at birth
or who are immunocompromised,
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ALTERNATIVES TO TRANSFUSION
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AUTOLOGOUS BLOOD COLLECTION AND
TRANSFUSION
 Preoperative collection.
 Frozen autologous blood
 Perioperative acute haemodilution.
 Intraoperative blood salvage.
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PLASMA EXPANDERS
 Crystalloid Solutions (Plasmalyte®)
 Gelatin Solutions (Gelofusin®)
 Dextran Solutions (Dextran 40, Dextran 70)
 Hydroxyethyl Starch (HES; HESPAN®;
PENTASPAN®:)
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OXYGEN CARRYING COMPOUNDS
 Although artificial blood in the form of perfluoro compounds and modified
haemoglobin solutions have been under investigation for many years
there is no indication that these compounds will be widely available for
routine use in the near future.
 Products based on polymerised haemoglobin Hemopure® (Biopure
Corporation), a bovine-derived product which despite safety concerns is
currently approved for human use in South Africa;
 PolyHeme® (Northfield Laboratories), which uses human
haemoglobin, has been taken to phase III clinical trials in the US,
 Second-generation products Hemospan® (Sangart) uses
humanhaemoglobin conjugated with polyethylene glycol (PEG) and is
currently in a phase II trial in the US and entering phase III trials in
Europe.
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HAEMOPOIETIC GROWTH FACTORS
 Recombinant Human Erythropoietin (rEPO; Epoetin
beta, EPRE X™, Recormon®)
 Granulocyte Stimulating Factor (G-CSF; Neupogen®)
 Thrombopoietin (TPO)
 Recombinant Coagulation Factors
 on-transfusion Therapy using Desmopressin (DDAVP;
Minirin®;Octostim®)
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Guidelines for rational use of blood

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