Dr.

JUMANA BAAJ
 In a 70 kg man total intravascular volume 5
Plasma 3 L and PRBCs 2L
Age Blood volume
Neonates
Premature 95ml/kg
Full-term 85ml/kg
Infants 80ml/kg
Adults
Men 75ml/kg
Female 65ml/kg
 Hematocrit
Healthy patient 18 %
Patients with well compensated 24 %
systemic disease
Patients with symptomatic cardiac 30 %
disease
 Observe blood suction from surgical field ,
sponges ,drapes .
 Acceptable blood loss to consider transfusion is :
◦ Estimate total blood volume
TBV(ml ) = weight (kg) x EBV (ml/kg )
TBV = 60 kg x75 ml/kg =4500
◦ Estimate red blood cell volume at preoperative
hematocrit Ex 42%
RBCVp (ml) = TBV (ml)x preoperative hematocrit /100
◦ Estimate RBVCp at hematocit 30/100
◦ RBVC30 %=TBV (ml)xo.3
- RBCV lost = RBCV preop – RBCV30%
- Allowed blood lost = RBCVlost x 3
 Blood groups :
ABO system and RH system
ABO system chromosomal locus for this system
produce three alleles A,B,O each represent
an enzyme that modifies a cell surface
glycoprotein producing different antigen
Individuals not having A,B naturally produce
antibodies (IgM) against those antigens
Presence of D antigen (Rh+), absence of D
antigen called Rh negative ,
 Compatibility testing :
◦ Predict and prevent antigen-antibody reaction as
result of red blood cells transfusion
 ABO – Rh testing
◦ Most sever reactions are due to ABO incompatibility
, naturally acquired antibodies can react against
transfused antigen and result intravascular
hemolysis .
◦ Patient red cells are tested with serum known to
have antibody against A,B to determine blood
group
◦ Patient RBC tested against anti-D antibody to
determin Rh
 Crosmatching :
1. Mimic transfusion
2. Serves three functions :
1. Confirm A,B O ,Rh type
2. Detect antibody to other blood group system
3. Detect antibody in low titer or those not aggulate
easily
 Crosmatches performed for elective
procedures for high transfusion probability
 Donors screened to exclude medical
condition Hematocrit , blood type , screened
for antibody , tested for Hep B, Hep c syphilis
HIV1, HIV 2
 Once blood is collected mixed with CPDA-1

◦ Citrate as anticoagulant
◦ Phosphate as buffer
◦ Dextrose RC energy source
Can be stored for 35 days .
Normal PRBCs unit contain 350 ml with HCT 70 %can
be stored 1-6 C
 PRBCs can be frozen in hypertonic glycerol
solution for up 10 years
 PRBCs :
◦ Indicated to increase oxygen carrying capacity
◦ Checked against blood bank slip and recipient
identity bracelet
◦ Transfusion tubing should contain a 170 mm filter
◦ Warmed to 37 C at flow rate 150ml /H
 Contain all plasma protein and all clotting factor
 Indication :
◦ isolated factor deficiency anemia
◦ Reversal of warfarin
◦ Correction of coagulopathy associated with liver disease .
◦ Used in patient received massive blood transfusion and
bleeding after platelet transfusion
◦ Used in antithrombin lll deficiency or thrombotic
thrombocytopenic purpura
◦ Each unit of FFP increase level of clotting factor 2-3 %
◦ Initial therapeutic dose 10-15 ml/kg
◦ The goal to achieve 30 %of normal coagulation factor
concentration
◦ Each unit of FFP carries same infection risk as whole blood
ABO compatibility test should be given
 Indication :
◦ Thrombocytopenia
◦ Platelet dysfunction
◦ Prophylactic in case platelet level below 20,000
because risk of spontaneous hemorrhage
◦ Platelet count should be more than 100,000 for
patient going for surgery or invasive procedure
◦ Each unit of platelet can increase platelet level
5000-1000x109
 Imunocomplication :
1. Hemolytic reaction :Due to destruction of transfused
red blood cells by recipient antibody
1. Acute hemolytic reaction : due to ABO incompatibility
reported 1:6000 transfusion
1. Causes : - misidentification of patient ,blood specimen
or transfusion unit
2. Risk of fatal hemolytic reaction 1 in 100,000transfusion
3. Symptoms in a wake PT chills , fever nausea , flank pain
4. In anesthetized Pt rise in temperature , un –explained
tachycardia . Hypotension , hemoglobin urea , oozing
in surgical field ,DIC
5. The severity of symptoms depend on volume of blood
had been transfused
---------cont
Management of hemolytic reaction :
1. Stop transfusion
2. Recheck the unit
3. Send blood sample to identify Hb and repeat
compatibility test
4. Insert urinary catheter to check UOP and
hemoglobin in the urine
5. Give mannitol and intravenous fluid
6. In presence of rapid blood loss and platelet loss
give FFP
 Delayed hemolytic reaction :
◦ Mild , 1 –1.6 % due antibody from non D ,ABO
system
◦ With re-exposure to other transfusion it will trigger
ammenstic antibody , delayed 2-21d post
transfusion
◦ Symptoms : malaise , jaundice ,fever , Hematocrit
fail to rise .
◦ diagnosis : coombs test (predict the antibody on
membrane of red cells )
◦ Treatment : supportive
2. Non hemolytic immune reaction :due to
sensitization of recipient to the donor white
blood cells ,platelet , plasma protein
1. Febrile reaction : WBC or platelet sensitization
Treatment : washed RBC , use 20-40 mm filter
2. Urticaria reaction : erythema, hives, itching due to
sensitization of the patient to plasma protein treated
with H1and H2 blockers
3. Anaphylactic reaction : 1in 150,000 occur after afew
mm of blood occur in IgA deficient Pt and has anti IgA
antibody
 Treatment : epinephrine , corticosteroid , fluid , H1,H2
blockers
 Should received washed PRBCs
Cont---
4. Non carcinogenic P E(acute lung injury )
1. Less 1:10,000
2. Due to transfuse antileukocyte or anti-HLA
antibody causes WBCs to aggregate on
pulmonary circulation and damage to
alveolar /capillary membrane
3. Same treatment to ARDS syndrom and typically
will resolved within 12-48 h
Cont—
5. Post transfusion pupura
1. It cause thrompcytopenia due to platelet
alloantibody and it destroy the PT platelet
2. Treatment : plasmapheresis
6. Immunosuppressant .
I. Viral (Hepatitis 88% of per unit viral risk)

 Hepatitis B
 Risk 1/ 200,000 due to HBsAg, antiHBc
screening (7-17 % of PTH)
 Per unit risk 1/63-66,000
 0.002% residual HBV remains in
‘negative’ donors (window 2-16 weeks)
 Anti-HBc testing retained as surrogate
marker for HIV
NANB and Hepatitis C

 Risk now 1/ 103,000 with 2nd/ 1/

125,000 with 3rd generation HCV Ab/
HVC RNA tests
 Window 4 weeks
 70 % patients become chronic

carriers, 10-20 % develop cirrhosis

HIV
 Current risk 1/ 450- 660,000 (95)
 With current screening (Abs to HIV I, II

and p24 Ag), window 6-8 weeks

(third generation ELISA tests in
Europe)
  sero -ve window to < 16 days
CMV
 Cellular components only
 Problem in immunocompromised,
although 80 % adults have serum Ab
 WBC filtration decreases risk of
transmission
 CMV -ve blood:
◦ CMV -ve pregnant patients, LBW
neonates, CMV -ve transplant
recipient,
 II. Bacterial
 Contamination unlikely in products
stored for > 72 hours at 1-6 0 C (10
cases Yersinia)
 Platelets stored at room temperature for
5 days, with infection rate of 0.25%

 III. Protozoal
 Trypanosoma cruzi (Chaga’s disease)
toxoplasmosis are very rare
 Coagulopathy
◦ Dilutional thrompcytopenia , dilutional coagulation
factor
 Citrate toxicity
◦ Citrate (3G/ unit WB) binds Ca2+ / Mg+
◦ Metabolized liver
◦ Hypocalcaemia ONLY if > 1 unit/ 5 min or
hepatic dysfunction
◦ Hypotension more likely due to  cardiac
out put due to hypocalcaemia
◦ Worse with hypothermia/ hepatic
dysfunction
 Hyperkalemia

 After 3 weeks, K+ is 25- 30 mmol/l

 Only 8- 15 mmol per unit PRBC/ WB
 Concern with > 1 unit/5 min @ infants
Acid – base balance
 Significant metabolic acidosis is not
common
 Significant metabolic alkalosis after
massive blood transfusion due to
transformation of bicarbonate from
citrate and lactate in liver
 Metabolic acidosis more likely due to
decreased perfusion, hepatic
impairment, hypothermia
 2, 3 DPG

 Depleted within 96 hours of storage

 O Hb DC to left
2
 Restored within 8- 24 hours of

transfusion
 Practice Guidelines for Blood
Component Therapy (ASA Task
Force). Anesthesiology 1996; 84:
732-47.
 Safety of the Blood Supply. JAMA
1995; 274:1368--73.
 Infectious Disease Testing for Blood
Transfusions (NIH Consensus
Conference). JAMA 1995; 274: 1374-
9.
 Blood Transfusion- Induced
Immunomodulation. Anesth Analg 1996; 82:
187-204
 ASA Questions and Answers about

Transfusion Practices (3rd ed., 1997)

 Immunomodulatory aspects of transfusion.

Anesthesiology 1999; 91: 861-5.

 “Blood is still the best possible thing
to have in our veins” - Woody Allen

 “Blood transfusion is a lot like

marriage. It should not be entered
upon lightly, unadvisedly or wantonly,
or more often than is absolutely
necessary” - Beal