AABB indications Elective surgeries- Maximum surgical blood ordering schedule Anemia and surgery- including Transfusion Trigger Surgery and coagulation disorders- including factor replacement Transfusion in cardiac surgeries- including autologous transfusion Patient Blood management in surgery Allogenic Transfusion Autologous Transfusion- Intra And Postoperative Red Cell Salvage, Haemodilution Blood Substitutes Haematopoietic Factors Antifibrinolytics Fibrin Sealants Conjugated Oestrogens. AABB pretransfusion testing schemes Type and screen Maximum surgical blood ordering schedule transfusion trigger for surgery factor replacement in surgery autologous transfusion cell salvage perioperative massive transfusion protocol

1. Transfusion support in
Surgery
MODERATOR- DR. ANSHUL GUPTA

2. INDEX
I. AABB indications
II. Elective surgeries- Maximum surgical blood ordering schedule
III. Anemia and surgery- including Transfusion Trigger
IV. Surgery and coagulation disorders- including factor replacement
V. Transfusion in cardiac surgeries- including autologous transfusion
VI. Patient Blood management in surgery

3. •In general surgery, blood transfusions are given to improve oxygen delivery to
tissues, based on the patient's physiological requirements.
•Under normovolemic conditions, the body responds to a loss of haemoglobin by
increasing the cardiac output, which affect hemodynamics during surgery.

4. Indications for Transfusion in surgery
Severe haemorrhage
Preoperatively anaemia correction
During major operation in which blood loss is inevitable
Postoperative anaemia
To arrest haemorrhage or as a prophylactic measure prior to operation in patients with
haemorrhagic status
Anaemia from chronic surgical conditions

5. Some surgical transfusion strategies include:
Allogenic Transfusion
Autologous Transfusion- Intra And Postoperative Red Cell Salvage, Haemodilution
Blood Substitutes
Haematopoietic Factors
Antifibrinolytics
Fibrin Sealants
Conjugated Oestrogens.

6. I. AABB Indications
In 2012, the American Association of Blood Banks (AABB) published their
clinical practice guidelines on the transfusion of RBCs, with recommendations
graded according to their level of evidence:
(1)The AABB recommends adhering to a restrictive transfusion strategy.
•In adult and paediatric ICU patients, transfusion should be considered at Hb
concentrations of 7g/dL or less.
•Quality of evidence: high; strength of recommendation: strong.

7. (2) In hospitalized, haemodynamically stable patients with pre-existing cardiovascular
disease, the AABB suggests adhering to a restrictive transfusion strategy.
•Transfusion should be considered at a Hb concentration of 8g/dL or less or for
symptoms (chest pain, orthostatic hypotension or tachycardia unresponsive to fluid
resuscitation, or congestive heart failure).
•Quality of evidence: moderate; strength of recommendation: weak.

8. (3) In hospitalized, haemodynamically stable patients with acute coronary
syndrome, 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.
(4) In hospitalized, haemodynamically stable patients, transfusion decisions
should be influenced by symptoms as well as haemoglobin concentration.

9. These recommendations are applicable in most postoperative patients, and also in
non-surgical patients, with the exception of patients with acute coronary
syndrome.
Transfusion should also be restricted in patients following an autologous blood
transfusion programme.

10. II. Transfusion practice in elective surgeries
Nowadays there is minimum blood loss during surgery because of meticulous
surgical techniques, use of tourniquets, use of vasoconstrictors, use of
antifibrinolytic drugs and good anaesthetic techniques.
For effective utilization of blood during surgical procedures and haemorrhage,
the clinician should have the knowledge about the blood volume of an individual
which is about 70 ml/kg in an adult male, 66 ml/kg in an adult female, 80 ml/kg
in children and 85 ml/kg in neonates.

11. Other points of consideration before transfusion
An average healthy individual with normal cardiovascular system can withstand
a loss of up to 500 ml of blood without any ill effects.
A healthy average adult may lose up to 1000 ml of blood or even more without
any ill effects, provided circulating blood volume is maintained by crystalloid or
colloid solutions.
Unnecessary transfusions especially of single unit of blood should be avoided in
surgeries.

12. Role of Surgical Blood Ordering Practices in
Elective Surgeries
•Component outdate rates are influenced by surgical ordering practices.
•For example, when RBC units are crossmatched for surgical patients, the shelf life of the
unit is shortened if the component is unused.
•When crossmatch to-transfusion (C:T) ratios are monitored, a C:T ratio of >2.0 may
indicate excessive ordering of crossmatched blood.
• One approach to reducing excessive C:T ratios is to identify procedures that do not
typically require blood, and use this information to develop guidelines for the use of type
and screen units instead of crossmatched units.

13. The policy of type and screen should be adopted universally for all patients even if they
don't currently require blood (e.g. cholecystectomy).
The request for single unit of blood in surgery is a common practice in India which by and
large has been seen as an act of thoughtlessness.
To avoid this-
Transfusion trigger may be lowered to 7.5 gm/dl of Hb and should be based on the rate of
development of anaemia and assessment of its effects on prognosis.
Each blood transfusion service should frame its Maximum Surgical Blood Order Schedule

16. III. Anemias and surgery
Most of the patients of elective surgery are anemic which are mostly Nutritional
deficiencies (iron and folate).
Many clinicians now accept the Hb of 7.5 g/d as transfusion trigger or the
preoperative Hb threshold in a well-compensated patient presenting for surgery.

17. •A higher pre-operative Hb level is required for elective surgery in following situations:-
•Inadequate compensation for anemia and the oxygen supply to tissues- Evidence of angina
•Increasing dyspnea or dependent oedema
•Patients with co-existing cardio respiratory disease like ischemic heart disease
•Major surgery or anticipated significant blood loss.
•Blood transfusion should rarely be used preoperatively to facilitate elective surgery.

18. Transfusion Trigger- Surgery
The intraoperative transfusion strategy should be based on patient’s Hb or
haematocrit concentration, amount of blood loss, haemodynamic changes or end-
organ ischaemia.
They recommended a Hb target 7.0–9.0 g/dL and a transfusion trigger of 7.5 g/dL.
The transfusion trigger for patients on cardiopulmonary bypass with moderate
hypothermia and those at risk of critical end-organ ischaemia is 6.0–7.0 g/dL.
In case of ongoing bleeding, a haematocrit of less than 30% is recommended as a
transfusion trigger.

19. Haemoglobin trigger in Cardiac surgery
•The Society of Thoracic Surgeons and Society of Cardiovascular 2011 guidelines
recommended PRBC transfusion for Hb <6 g/dL during cardiopulmonary bypass
and <7 g/dL post-operatively, except in patients at risk for decreased cerebral
oxygen delivery, for whom a higher Hb level is recommended.
•A restrictive Hb of 7-8 gm/ dl (Hct 21-24%) with a patient maintaining an
adequate O2 delivery > 273 ml O2/min/m2 can be considered during
cardiopulmonary bypass.

23. IV. Surgery and coagulation disorders
•Diagnosis and treatment of coagulation disorders prior to any surgical procedure
by haematologist is important to prevent excessive operative blood loss, which
may lead to uncontrolled haemorrhage during surgery.
•INR should be less than 2 before surgery commences.
•Some drugs like aspirin and NSAIDS interfere with platelet function, thus
stopping of such drugs 5-6 days before surgery can significantly reduce operative
blood loss.

24. Factor replacement in surgery
Factor replacement on demand shall be performed during spontaneous or
traumatic bleeding episodes
Dose (Factor VIII):
Bleeding into joints and muscles (30-40 IU/kg)
life-threatening (80-100 IU/kg),
surgery (major bleeding 80-100 IU/kg)
minor wounds (50-100 IU/kg)

25. For surgical prophylaxis,
Factor VIII and IX levels should be maintained above 50% for 7-15 days after surgery
The plasma fibrinogen levels of at least 1 g/L should be aimed from beginning prior to
surgery and continued till wound healing.

26. Albumin in Surgery
Cardiac surgery: Last choice of treatment after crystalloids and non-protein colloids
•Major surgery: Not in the immediate postoperative period. The only indication for
use is albumin less than 2 g/dL after normalization of circulatory volume

27. V. Blood transfusion in cardiac surgery
•Autologous blood transfusion is the most commonly used transfusion protocol.
•Acute isovolemic haemodilution improves microcirculatory blood flow due to decrease in
the viscosity of blood.
•Use of cell saver machine helps to use the intra-operative mediastinal shed blood safely.
•There is no indication to use freshly drawn blood. The concept that transfusion of fresh
blood reduces bleeding during cardiac surgery is no longer accepted.
•Blood components- platelets or FFP are not routinely used during cardiac surgery.

28. Pre-operative transfusion in Surgery
•Preoperative erythrocyte transfusion is not routinely recommended in elective surgeries.
•However, it is used in emergency surgery and life-threatening anaemia.
•Oral or intravenous iron alone may be considered in mildly anaemic patients (women-
Hb 10–12 g/dl; men- Hb 10–13 g/dl) or in severely anaemic patients (both genders, Hb
< 10 g/dl) to improve erythropoiesis prior to surgery.
•Erythropoietin with iron supplementation should be considered to reduce postoperative
transfusions in patients with non-iron deficiency (e.g., EPO, vitamin D or folate)

29. Pre-operative autologous blood donation
•In patients posted for elective surgery with Hb > 11 gm/dl and without severe aortic stenosis or an acute
coronary syndrome within 4 weeks.
Some of the indications of preoperative autologous blood deposit may include:
• Orthopaedic surgery (joint replacement)
• Plastic and reconstructive surgery
• Cardiovascular surgery
• Major abdominal surgery (elective splenectomy)
• Individuals with rare blood group/ with multiple alloantibodies/antibodies to high-frequency antigens

30. Contraindications for preoperative autologous blood
donation:
• Bacteraemia and/or acute localized infection
• Myocardial infarction in the past 6 months
• Unstable angina / angina at rest
• Aortic stenosis
• Congestive heart failure
• Significant ventricular arrhythmia
• Marked uncontrolled hypertension
• Cerebrovascular accident within 6 months
• Transient ischemic attack

31. Perioperative autologous blood donation
Acute normovolemic haemodilution:
It involves removing whole blood from the patient into a standard blood bag
containing anticoagulant, either immediately before or shortly after the induction
of anaesthesia in the OT with the maintenance of normovolemia using crystalloid
and colloid replacement.

32. Perioperative Reinfusion:
•Patients of ANH should be monitored regularly during surgery, and the decision of
reinfusion depends on the anaesthesiologist’s/surgeon’s assessment of blood loss.
•Usually, blood is reinfused when haemoglobin level falls in the range of 7-8 g/dl.
•The units of blood are reinfused to the patient in the reverse order of collection- This
allows the most concentrated unit to be transfused at the time of least bleeding.
•Hence, the first unit, containing the highest haemoglobin, the maximum number of
platelets and undiluted coagulation factors, is administered last.

33. Intraoperative blood salvage
•The process of collecting shed autologous blood and its processing and re-
administration has been termed as cell salvage, auto transfusion, intraoperative blood
recovery, and cell saving.
•It can happen either in the intraoperative period or in the post-operative period.
•Salvage involves washing of the collected blood, or it may be simply re-administered
with micro aggregate filtration.
•Blood salvage in surgical procedures is recommended if there is the expectation of a
significant blood loss (greater than 1 litre).

35. Postoperative blood salvage
•Postoperative blood salvage refers to collecting blood from surgical drains and subsequent
reinfusion through a 40-micron microaggregate filter, with or without washing.
•These techniques available for collecting the postoperative drainage are usually of worth
if blood collection can be done within 24 to 48 hours after surgery in patients actively
bleeding into a closed site.
This practice is generally limited to cardiac and orthopedic surgery.

37. Transplantation surgeries
Before surgery, a crossmatch between recipient serum and donor lymphocytes is required.
The ASHI Standards for Accredited Laboratories requires that the crossmatch be performed
using a method that is more sensitive than routine microlymphocytotoxicity testing, such as
prolonged incubation, washing, augmentation with AHG reagents, or flow cytometry
Because HLA antibody responses are dynamic, the serum used for the crossmatch is often
obtained within 48 hours of surgery for sensitized potential recipients and is retained in the
frozen state for any required subsequent testing.
An incompatible crossmatch with unfractionated or T lymphocytes is typically a
contraindication to transplantation surgeries.

38. Equipments common in surgical
transfusions
•Blood warmers are used when rapid transfusion of components is required,
especially in massive blood loss during surgery settings.
•Microaggregate filters are typically used for the reinfusion of shed autologous
blood collected during or after surgery.

39. VI. Patient Blood Management
•The concept of patient blood management introduced by the WHO in 2011 is a systematic
approach focused on weighing the benefits of transfusion against the risk, with minimal
transfusion-related adverse events.
•Perioperative blood management is based on a thorough preoperative assessment of patients
by correcting any reversible cause of anaemia instead of going for allogenic transfusion.
•Preoperative blood transfusions are recommended only in patients with persistent bleeding,
urgent or emergency surgery or cancer-related surgery where surgery cannot be delayed.

43. References
1) AABB (Association for the Advancement of Blood and Biotherapies) Technical Manual, 21st edition, 2023
2) Modern Blood Banking & Transfusion Practices. Denise M. Harmening 7th Edition. 2019.
3) Principles and practice of Transfusion Medicine by Dr. R. Makroo, 2nd Edition (2019)
4) Transfusion Medicine, Technical Manual. DGHS, Ministry of Health and Family Welfare Govt. of India. 3rd
Edition. 2022