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INFORMATION SHEET FOR CANDIDATE

You are the only HMO in a small country town hospital


when a new resident arrives. He is an IMG from Germany
who has never worked in Australia. He has done his
internship back in Germany and arrived 4 weeks ago to take
up a resident position in general surgery at your hospital.
He has been granted temporary registration by the Medical
Board but he has not set any AMC examinations yet. Your
job is to orientate him to the hospital and he asks you about
the local policies regarding blood transfusions.and the
guidelines on the use of blood components.
YOUR TASKS ARE TO:
1. Explain the clinical practice guidelines on the use of
blood components to the new doctor.
2. Discuss the cross matching and blood administration
process

GENERAL COMMENTS:

Blood components should only be given when clearly indicated! I.e. when the expected
benefits to the patient are likely to outweigh the potential hazards!!!
Blood transfusion in Australia is very safe because we have a rigorous screening program
in place (incl. HIV, HBC, HCV and syphilis), although one can not exclude 100% rare
infections with Hep G or prion (Creutzfeld-Jacob disease, CJD).
Blood is usually given with reservations and in otherwise healthy patients not considered
unless Hb <80g/L
WHOLE BOOD:
The total blood volume of a 70 kg adult is approximately 75 ml/kg or 5 litres.
Whole blood has limited usefulness as a transfusion therapy. Although it can
provide both volume and oxygen-carrying capacity, this is often better achieved
using the individual blood components.
Disadvantages of whole blood, partially because of degradation during storage,
include low levels of clotting factors, frequently elevated levels of potassium,
hydrogen ion and ammonia, and the presence of a large number of antigens. It also
can cause circulatory overload!
A unit of whole blood contains about 500 ml of blood plus a preservativeanticoagulant:
i. Citrate - anticoagulant
ii. Phosphate - reduces haemolysis
iii. dextrose - energy source for RBC
iv. adenine. maintains ATP levels
PACKED RED BLOOD CELLS:
Red blood cell replacement is usually done with packed red blood cells , primarily
to increase oxygen-carrying capacity!!!
One unit of packed cells (about 300 mls) raises an adults haemoglobin by 1 g/dl
or the haematocrit by 3% and is usually transfused over 1 to 2 hours unless there is
haemodynamic instability.
ADVANTAGES OVER WHOLE BLOOD: longer life, less storage lesions /
citrate /Na / K, less antigens transferred
DISADVANTAGES: slower flow, smaller volume, higher viscosity
INDICATIONS:
o Hb level <7g/dl
o Hb level < 10 g/dl if significant symptomatic angina or CCF or syncope or
active bleeding!
o Hb should not be the sole deciding factor. Consider also patient factors,
signs and symptoms of hypoxia, ongoing blood loss and the risk to the
patient of anaemia.
PLATELETS:

Each unit of 50 mls should raise the platelet count by 5 x 109/L

They do not need ABO compatibility

INDICATIONS:
- bleeding and platelets < 50 or skin bleeding time >2x!
- born marrow failure with platelets <109/L
- platelet dysfunction

In addition to 5 litre blood transfusion (6-8 units!)


In thrombocytopaenic patients to either prevent bleeding or to help active bleeding
In bone marrow failure (usually malignancies) if platelet count <10x109 /L

FRESH FROZEN PLASMA:


180 ml bags
must be ABO compatible
contains
- all clotting factors
- 200 mg VIII and IX
- 400 mg fibrinogen
each unit to be infused in no more than one hour
INDICATIONS:
- haemorrhage and coagulopathy
- reversal of warfarin over-anticoagulation (in addition to Vit K!)
- factor deficiency and no concentrate available
- antithrombin (AT) III deficiency
- alternative to gammaglobulin
-acute disseminated intravascular coagulopathy (DIC)
-thrombotic thrombocytopaenic purpura (TTP)
4-6 units usually required with each blood volume replacement (5 L)
CRYOPRECIPITATE:
15 ml frozen plasma
150 units VIII
fibrinogen 250 mg
XIII and VWF
INDICATIONS:
bleeding and fibrinogen <1.0 g/L (most often trauma or
DIC)
COMPLICATIONS:
1. incompatible blood transfusion (e.g. wrong blood to wrong patient!!!)
2. acute and delayed transfusion reactions
3. transfusion related acute lung injury
4. graft-versus-host disease (in immunodepressed patients like Hodgkins!)
5. post transfusion purpura
6. infection transmitted by transfusion (Hep B + C, syphilis and HIV good
screening program in Australia, ?Hep G + CJD no screening available!)
7. microaggegates, usually 20-17- micrometers in diameter (blood filters!)
To minimize side effects e.g. directly associated with red blood cell transfusion, measures
may be taken like leucocyte filtration, phenotyping, washing and irradiation!
ACUTE TRANSFUSION REACTION:
SIGNS + SYMPTOMS:
shock, fever, low back and/or chest pain, flushing,
dyspnoea, tachycardia, haemoglobinuria, actue renal failure, DIC.
MANAGEMENT:
STOP transfusion!, ensure adequate hydration and
maintain diuresis, retype and cross-match, possibly antihistamine and antipyretic!

AUTOLOGOUS BLOOD TRANSFUSION:


1. Preoperative autologous deposit
With Preoperative Autologous Deposit (PAD), blood (almost always whole blood or red
cells) may be collected and stored (usually fresh or occasionally frozen) prior to planned
surgery. Autologous blood collections are only recommended where there is a reasonable
expectation that the blood product will be required for the condition or procedure. Donor
suitability for autologous collections is assessed based on the ability of the donor to
tolerate several venesections taken over a short period of time, age, adequate venous
access, and reliable dates for elective surgery. Autologous blood collections are subject to
the same testing criteria as allogeneic donations within ARCBS.
When should I donate my blood?
Blood can be stored for 35 days at 4 degrees C. Donations can therefore commence up to
4 weeks prior to your surgery, with intervals of at least 1 week between each donation,
depending on requirements.
Your own blood is drawn 2-4
weeks before surgery, is
Avoids the need to transfuse
tested, and stored in blood
blood from someone else.
bank until or if needed.

Must be done in advance (2-4


weeks) & may delay surgery.
Not all patients are
candidates

2. Acute normovolaemic haemodilution


Acute normovolaemic haemodilution is a technique of autologous blood removal
immediately prior to surgery, with volume replacement by crystalloid solutions and
reinfusion of the blood during or after surgery.
3. Perioperative blood salvage
Perioperative blood salvage is a technique in which shed blood is collected and processed
for reinfusion. Systems designed to collect and reinfuse shed blood range from the simple
to the complex. These should not be used where there is infection or malignancy in the
operative field.
Blood lost in the wound is
collected by a machine called
Cell Saver. The blood is
recycled and given back to
the patient as needed later..

Avoids the need to transfuse


blood from someone else.
Large amount of blood can
be given back during or after
the operation.

Can not use in cancer or


infection. Not available
everywhere. Rarely can
cause allergic reactions or
kidney failures.