Indian J. Anaesth.
2004; 48 (6) : 446-453
446
CURRENT AND EVOLVING ISSUES IN
TRANSFUSION PRACTICE
Dr. Sharmila Ahuja1
SUMMARY
It has been recognized by WHO that anaesthesiologists, who are perioperative physicians, are the major users of blood and blood
products. Therefore a thorough knowledge of transfusion practices becomes imperative in this speciality. With the recent development
of transfusion practices, various organizations such as WHO and American Society of Anaesthesiologists Task Force have laid down
specific guidelines for the use of blood and blood products. This review deals with the major guidelines in transfusion practices and
the alternative management strategies.
Keywords : Transfusion : Blood and blood products, Guidelines, Controversies.
Introduction
‘We few, we happy few, we band of brothers:
For he today that sheds his blood with me
Shall be my brother.’
Shakespeare: Henry V (act 4,scene3)
It is rather surprising that, though bloodletting
(venesection) was widely practiced from the time of
Hippocrates (430 BC), blood transfusion only became a
commonplace therapeutic intervention less than 100 years
ago. This is because both an understanding of the nature of
blood as well as the physiology of the circulation were
required as a foundation for the development of blood
transfusion and these were not forthcoming until the middle
of the seventeenth century. The outbreak of the Second
World War provided a great stimulus for the development
of blood transfusion services. The outbreak of war also
stimulated work directed towards fractionation of blood.
Though the services have made tremendous advances over
the last two decades many controversies have arisen in
various aspects of this field.
According to the Webster dictionary, ‘controversy’
is a discussion marked especially by the expression of
opposing views; Disputable.
In the field of transfusion practice, controversies
exist in the following areas -
When to transfuse? What to transfuse? How much to
transfuse?
1. M.D.,D.A., Prof.
2. M.D.,D.N.B., Jr. Specialist
Department of Anaesthesiology and Critical Care,
University College of Medical Sciences
and Guru Teg Bahadur Hospital,
Dilshad Garden, Delhi 110095.
Correspond to :
Dr. Poonam Motiani
A-199, Sector 26, Noida (U.P) - 201301.
E-mail : rajivmotiani@yahoo.com
(Accepted for publication on 17-9-2004)
INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2004
446
REVIEW ARTICLE
Dr. Poonam Motiani2
It is now well established that these queries are
applicable to all areas of transfusion such as Whole blood,
Blood components, Transfusion techniques and Alternatives
to blood transfusion .This review addresses the controversies
regarding the use of blood and blood products, emerging
techniques in transfusion practice and alternatives to blood
transfusion.
Blood and Blood products
Blood product is any therapeutic substance prepared
from human blood
Whole blood is unseparated blood collected into an
approved container containing an anticoagulant – preservative
solution
Blood component
a. A constituent of blood, separated from whole
blood, such as:
• Red cell concentrate
• Red cell suspension
• Plasma
• Platelet concentrates
b. Plasma or platelets collected by apheresis.
c. Cryoprecipitate, prepared from fresh frozen plasma
which is rich in Factor VIII and fibrinogen.
Plasma derivative are human plasma proteins prepared
under pharmaceutical manufacturing conditions, such as:
• Albumin
• Coagulation factor concentrates
• Immunoglobulins
In an effort to improve transfusion practices,
minimize risk of adverse transfusion reactions, and
decrease costs, a number of groups namely World Health
Organization1 (WHO), American Society of Anaesthesiologists
AHUJA, MOTIANI : ISSUES IN TRANSFUSION PRACTICE
Task Force,2 American College of Physicians3 (ACP),
British Haematological Society and College of American
Pathologists4 (CAP) etc. have issued clinical practice
guidelines for blood and blood component therapy.
Whole blood and RBC transfusion
According to WHO guidelines, the indications for
the transfusion of whole blood are1:
i. Red cell replacement in acute blood loss with
hypovolemia.
ii. Exchange transfusion.
iii. Patients needing red cell transfusions where red cell
concentrates or suspensions are not available.
The controversies, which exist regarding whole blood
and RBC transfusion, may be addressed by the following
observations:
a. Clinical5 and experimental6 observations in hypovolemic
(haemorrhagic) shock suggest that the combination of
packed red blood cells with crystalloid or albumin is
as effective as whole blood in correcting a volume
deficit. Many patients who have sustained a blood
loss do not need a whole blood transfusion and
should not be exposed to the associated risks. Whole
blood carries the risk of transmitting any agent
present in cells or plasma which has not been detected
by routine screening for transfusion-transmissible
infections, including HIV-1 and HIV-2, Hepatitis
B and C, other hepatitis viruses, syphilis, malaria
and chagas disease.
b. Single unit transfusions was thought to be useful in
certain clinical situations such as elderly surgical
patients with coronary disease, patients who have
sustained an acute loss of two to three units who
achieve circulatory stability with one unit, and patients
whose bleeding during surgery or from the
gastrointestinal tract is controlled after transfusion
of the first unit.7,8 However, in recent times, the
utility of this practice has been questioned. It has
now been established that the hazards and risks of
transfusion far outweigh the benefits of single unit
transfusion.9
c. Transfusion Trigger : The transfusion of erythrocyte
products to correct anaemia is rooted in the
assumptions that it is possible to accurately monitor
anaemia, it is possible to identify when anaemia impairs
tissue oxygenation and that erythrocyte transfusions
improve tissue oxygenation.
447
However, a single hematocrit or haemoglobin level
cannot be used as a transfusion trigger in all patients.
Some authors have recommended using physiologic
markers of impaired tissue oxygenation such as O2ER
(Oxygen Extraction Ratio) which should be superior to the
haemoglobin and hematocrit as transfusion triggers in
individual patients in the ICU.10-13 Oxygen extraction can
be monitored continuously by using pulse oximetry (for
arterial O2 saturation) and mixed venous oximetry (for venous
O2 saturation).
Recommendations for RBC transfusion by American
College of Physicians3 (ACP)
In 1992 ACP recommended distinguishing
between stable and unstable vital signs in determining
whether to transfuse anaesthetised patients. They concluded
that patients with stable vital signs and no risk of myocardial
and cerebral ischaemia do not require RBC transfusion,
independent of hemoglobin level, and recommended
transfusing patients with unstable vital signs only if risks of
myocardial or cerebral ischaemia were present.3
The current recommendations for RBC transfusion
(as laid down by the task force established by the American
Society of Anaesthesiologists in 1996) are:2
i. Transfusion is rarely indicated when the hemoglobin
concentration is >10 gdL-1. It is almost always indicated
when the hemoglobin concentration is<6 gdL-1
especially when the anemia is acute.
ii. Whether RBC transfusion is required with intermediate
hemoglobin concentrations (6-10 gdL-1) depends on
the patient’s risk for complications of inadequate
oxygenation.
iii. The use of a single hemoglobin “trigger” is not
recommended.
iv. When appropriate, preoperative autologous blood
donation, intraoperative and postoperative blood
recovery, acute normovolemic hemodilution, and
measures to decrease blood loss (deliberate hypotension
and pharmacologic agents) may be beneficial.
v. Indications for transfusion of autologous RBC’s may
be more liberal than for allogenic RBC’s because of
the lower risks associated with the former.
Some other controversies regarding transfusion
management include:
a. Whether blood should be warmed prior to transfusion?
b. Does Hypocalcemia occur with the administration of
blood?
448
Warming blood
There is no evidence to show that warming blood
is beneficial to the patient when the infusion is slow. At
infusion rates greater than 100 mlmin-1, cold blood may be
a contributing factor in cardiac arrest. However, keeping
the patient warm is probably more important than warming
the infused blood. If blood needs to be warmed, it should
be done only in a blood warmer. Blood should never be
warmed in a bowl of hot water as this could lead to
haemolysis of the red cells which could be life threatening.1
Warmed blood is most commonly required in :
• Large volume rapid transfusions
Children : greater than 15 mlhr-1
Adults : greater than 50 mlhr-1
• Exchange transfusion in infants
• Patients with clinically significant cold agglutinins
Citrate toxicity and hypocalcemia
Citrate toxicity is rare but is most likely to occur
during the course of a large volume transfusion of whole
blood.
Ionized hypocalcemia has been reported in 15%
of patients receiving blood transfusions, the mechanism
being calcium binding by the citrate preservative in banked
blood. Hypocalcemia from blood transfusions usually is
transient, and resolves when the infused citrate is metabolized
by the liver and the kidneys. Although hypocalcemia
from blood transfusion could impede blood coagulation, this
is no longer considered a significant effect and calcium
infusions are no longer recommended in massive blood
transfusions.1
Hypocalcemia, however, in combination with
hypothermia and acidosis, can cause a reduction in cardiac
output, bradycardia and other dysrhythmias and must be
corrected in these circumstances.
Platelet concentrates
Considerable advances have been made in platelet
transfusion therapy in the last 40 years, but some areas
continue to provoke debate.
The scientific rationale for transfusing platelets rests
on these principles :
• Surgical patients experience adverse outcome as a
result of thrombocytopenia and/or platelet dysfunction
• Platelet transfusion can correct platelet defects and
thereby reduce, minimize, or prevent bleeding.
Platelet count in humans ranges from 15-40x1010 l-l
(150,000 to 400,000 mm-3). Transfusion of one platelet
INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2004
concentrate increases the platelet count by 5-10 x 109 L-l in
an average adult. The usual therapeutic dose is one platelet
concentrate per 10 kg body weight.
Indications for platelet transfusions are (according
to WHO guidelines)1:
a. Treatment of bleeding due to :
- Thrombocytopenia
- Platelet function defects
b. Prevention of bleeding due to thrombocytopenia, such
as in bone marrow failure.
Contraindications
a. Not generally indicated for prophylaxis of bleeding
in surgical patients, unless known to have significant
pre-operative platelet deficiency.
b. Not indicated in:
- Idiopathic autoimmune thrombocytopenic purpura (ITP).
- Thrombotic thrombocytopenic purpura (TTP).
- Untreated disseminated intravascular coagulation (DIC).
- Thrombocytopenia associated with septicemia,
until treatment has commenced or in cases of
hypersplenism.
In 1994, The CAP (College of American Pathologists)4
recommended :
i. Platelet transfusion in patients with platelet count <
5 x 109L-l.
ii. They also recommended considering prophylactic
platelet transfusion in patients with platelet count
between 5 x 109 L-l and 30 x 109 L-l.
iii. For major surgery with life threatening bleeding they
recommended maintaining platelet counts >50x109 L-l.
iv. They also recommended transfusing platelets to
patients with enhanced platelet destruction and
with platelet counts < 50 x 109 L-l with microvascular
bleeding.
Some experts have recommended transfusing platelets
to patients after CPB, with normal coagulation values, with
platelet count of <100 x 109L-l when major unexplained
bleeding occurs.
Prophylaxis for surgery
The guidelines laid down by the American Society
of Clinical Oncology in the year 2001 are as under14:
i. Bone marrow aspiration and biopsy may be performed
in patients with severe thrombocytopenia without
platelet support, providing that adequate surface
pressure is applied.
AHUJA, MOTIANI : ISSUES IN TRANSFUSION PRACTICE
ii. For lumbar puncture, epidural anaesthesia,
gastroscopy and biopsy, insertion of indwelling lines,
transbronchial biopsy, liver biopsy, laprotomy, or
similar procedures, the platelet count should be raised
to at least 50 x 109L-l.
iii. For operations in critical sites such as the brain or eyes,
the platelet count should be raised to 100 x 109L-l.
iv. It should not be assumed that the platelet count will
rise just because platelet transfusions are given, and
a preoperative platelet count should be checked to
ensure that the above thresholds have been reached.
The current recommendations for platelet transfusion
as laid down by the American Society of Anaesthesiologists
Task Force are2:
i. Prophylactic platelet transfusion is ineffective and
rarely indicated when thrombocytopenia is due to
platelet destruction (e.g.ITP).
ii. Prophylactic platelet transfusion rarely indicated in
surgical patients when count > 100 x 109L-l; usually
indicated when count < 50 x 109L-l; When intermediate
platelet counts (50-100 x 109L-l) whether therapy is
required should be based on the risk of bleeding.
iii. Surgical and obstetric patients with microvascular
bleeding usually require transfusion if count is
<50 x 109L-l; rarely require therapy if count > 100
x 109L-l. With intermediate counts (50-100 x 109L-l) -
the determination is based on patient’s risk for more
significant bleeding.
iv. Vaginal deliveries or minor operative procedures
may be undertaken in patients with platelet count
< 50 x 109L-l.
v. In patients with known platelet dysfunction and
microvascular bleeding, despite adequate count
platelet transfusion may be indicated.
Specialized products and emerging techniques
Several specialized blood or blood components are
available to meet distinct clinical needs.
a. Cytomegalovirus negative or leukoreduced blood -
blood components should be administered to
immunocompromised individuals (e.g., bone marrow
or solid organ transplant patients, preterm infants,
pregnant women).
b. Leucocyte - depleted Red cells - A red cell suspension
or concentrate prepared by filtration through a
leucocyte-depleting filter reduces the risk of
transmission of cytomegalovirus (CMV) and HIV,
449
avoids nonhemolytic febrile reactions and also prevents
sensitization of patients with aplastic anaemia who
may be candidates for marrow transplantation.1,15
c. Refractoriness to transfusion is a common occurrence
in patients receiving frequent platelet transfusion
and may be related to fever, infection, disseminated
intravascular coagulation, splenomegaly, excessive
bleeding, or various drugs. However, platelet-reactive
and/or lymphocytotoxic antibodies are the factors that
most strongly correlate with this refractoriness. Type
specific or HLA matched platelets may be helpful for
immune refractoriness to platelet transfusion.2
Gamma irradiation of platelets
Platelets can be irradiated at any stage during their
5 d shelf life.The minimum dose in the irradiation field is
25 Gy.16 These are indicated in patients at risk of transfusion
associated graft versus host disease (TA-GVHD) which is
the most frequent cause of transfusion associated death.
TA-GVHD is more frequently seen in patients who require
repeated transfusions and those who are immunocompromised.
Fresh frozen plasma
Fresh frozen plasma (FFP) is prepared by separating
the plasma from whole blood within 6 hrs of collection and
then rapidly freezing to –250 C or below. It contains the
normal plasma levels of stable clotting factors, albumin
and immunoglobin. The usual volume of a pack is 200-300
ml. If untreated it carries the same risk of disease
transmission as whole blood. If kept at -250 C it can be
stored for a year. Before use, it should be thawed in
the blood bank to 30-370 C. Once thawed it should be stored
in a refrigerator at 2-60 C. The dose for administration is
15 mlkg-1. ABO compatibility is required to avoid risk of
haemolysis in the recipient. However compatibility testing
(crossmatching) is not mandatory. Since it contains labile
coagulation factors that rapidly degrade, it should be used
within 6 hrs of thawing. The Controversies, which exist
regarding fresh frozen plasma transfusion, are :
a. When/How much should be transfused?
b. Should it be given to augment the plasma volume or
albumin concentration?
The Current Recommendations for fresh frozen plasma
transfusion as laid down by the Task force (in 1996)
i. For urgent reversal of Warfarin therapy.
ii. For correction of known coagulation factor deficiencies
for which specific concentrates are unavailable.
iii. For correction of microvascular bleedintg in the
presence of elevated (>1.5 times normal) PT or PTT.
450
iv. For correction of microvascular bleeding secondary
to coagulation factor deficiency in patients transfused
with more than one blood volume and when PT and
PTT cannot be obtained in a timely fashion.
v. FFP should be given to achieve a minimum of 30%
of the plasma factor concentration (about 10-15 mlkg-1
of FFP), except for urgent reversal of warfarin
anticoagulation (about 5 mlkg-1).
vi. FFP is contraindicated for augmentation of plasma
volume or albumin concentration.
Because of all the alternatives available and the
many hazards associated with FFP transfusion, the use of
FFP as a plasma expander or to enhance wound healing is
contraindicated.4
Cryoprecipitate
Cryoprecipitate or cryoprecipitated antihaemophilic
factor (cryo), is the cold precipitable protein fraction
derived from FFP thawed at 1-60 C. It contains factor VIII,
fibrinogen, fibrinonectin, Von willebrand’s factor and
factor XIII.
It’s use in the operative setting is based on the
assumption that :
a. Patients with these coagulation factor deficiencies are
at increased risk of haemorrhagic complications.
b. Replacement of coagulation factors is effective in
decreasing these risks.
1 unit of cryoprecipitate per 10 kg body wt raises
plasma fibrinogen concentration by approximately
50 mgdl-1 in the absence of continued consumption or
massive bleeding.
Recommendations by the Task force for Cryoprecipitate
transfusion2
i. The administration of Cryo is recommended for
prophylaxis in non bleeding perioperative or peripartum
patients with congenital fibrinogen deficiencies or
Von Willebrand’s disease unresponsive to DDAVP.
ii. Bleeding patients with Von Willebrand’s disease.
iii. Correction of microvascular bleeding in massively
transfused patients with fibrinogen concentration cannot
be measured in a timely fashion.
Plasma Derivatives
The Human Albumin controversy
Though Albumin was widely used in anaesthesia and
intensive care practice ten years ago, the routine use of
albumin has become more and more debatable.
INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2004
Albumin is prepared by fractionation of large pools
of donated plasma.
Availability –
Albumin 5 % (contains 50 mgml-1 of albumin),
Albumin 20 %, Albumin 25 %, stable plasma protein
solution (SPPS) and plasma protein fraction (PPF)
Indications for transfusion of albumin as laid down
by WHO are1 :
- As a replacement fluid in therapeutic plasma exchange:
Use albumin 5 %
- Treatment of diuretic resistant oedema in
hypoproteinaemic patients : e.g. nephrotic syndrome
or ascites. Use albumin 20 % with a diuretic.
- Although 5 % human albumin is currently licensed for
a wide range of indications (e.g.volume replacement,
burns and hypoalbuminaemia), there is no evidence
that it is superior to saline solution or other crystalloid
fluids for acute plasma volume replacement.
Precautions : Administration of 20% albumin may
cause acute expansion of intravascular volume with risk of
pulmonary oedema.
Contraindications
Do not use for I.V. nutrition. It is an expensive and
inefficient source of essential amino acids.
Advantages
- No compatibility testing required
- No filter needed
- No risk of transmission of viral infections if
correctly manufactured
The theoretical benefits of albumin replacement are
not readily demonstrated in clinical studies. A systematic
review of the use of albumin has fuelled an interesting
debate, but has shown that the injudicious use of intravenous
albumin may be detrimental.17
Management alternatives in transfusion practice
In order to circumvent the risks and hazards of
Allogenic Transfusion, some alternatives in transfusion
practice have evolved over the past decade. They include:
• Autologous Blood Transfusion
• Red Cell Salvage
• Use of Blood Analogues
Autologous blood transfusion
It involves the collection and subsequent reinfusion
of the patient’s own blood or blood products.
AHUJA, MOTIANI : ISSUES IN TRANSFUSION PRACTICE
The controversies, which exist regarding autologous
blood transfusion, are :
- Which patients is it suitable for?
- Should all the blood that has been collected from the
patient be transfused irrespective of whether it is
required or not?
- Should the unused blood be transferred to the allogenic
pool for the benefit of other patients?
Different methods of autologous blood transfusion
a. Predeposit donation
b. Acute normovolemic haemodilution.
Indications
- Patients to undergo elective surgery with expected
loss > 20% TBV.
- When there is difficulty in obtaining the compatible
blood group for e.g. if the patient has a rare blood
group or multiple red cell antibodies are present.
- As a general strategy for the avoidance of the risks
(infectious and immunological) of allogenic transfusion.
Contraindications
Aortic stenosis, unstable angina, left main stem
disease or equivalent, moderate to severe left ventricular
impairment.
Advantages
Widely available, low cost option with the potential
advantage of a reduction in blood viscosity.
Potential adverse effects
Requires adequate monitoring and maintenance
of normovolemia to prevent hemodynamic stability and
possible myocardial ischaemia in susceptible patients.13
WHO specifies that all the units collected by
predeposit donation need not be transfused back to the
patient unless indicated. Also, the unused units of blood
should not be transferred to the allogenic pool for the
benefit of other patients unless they have been tested for
other disease markers such as HbsAg and anti-HIV.1
Acute normovolemic haemodilution involves the
removal of a predetermined volume of the patient’s own
blood immediately prior to commencement of surgery and
subsequent reinfusion, preferably when surgical bleeding
has been controlled. The fresh units of autologous blood
contain a full complement of coagulation factors and
platelets.
451
Red cell salvage
Blood salvage is the collection of blood from a wound,
body cavity or joint space and its subsequent reinfusion into
the same patient.
The controversies regarding this technique are when
should it be used? Should salvaged blood be re-infused
always? How useful is this technique? Is it safe?
Blood salvage can be useful in procedures involving
major surgical haemorrhage. Adequate processing and
washing of scavenged blood is very important. This avoids
potentially life threatening bleeding and pulmonary
complications that can occur as a result of reinfusion of
cellular and tissue debris that may be scavenged in certain
procedures (e.g., orthopaedic procedures). Use of cell
salvage systems can also result in haemodynamic, hemolytic
(related to centrifugation), or bleeding complications such
as DIC from cellular debris or from loss of coagulation
factors such as platelets. The relative efficacy of
retransfusion of shed wound blood or cell salvaged processed
autologous blood has been controversial, and the potential
safety has been questioned recently. Linden et al18 recently
reported a death rate of 1:30,000 during cell salvage
procedures during a 5 yr period in New York state. This
was related to air embolism.
The indications as per WHO guidelines are:
• Patients to undergo elective and emergency surgery
with expected loss > 20% TBV.
• Acceptable to some Jehovah’s witnesses.
Contraindications
• Bacterial contamination of operative field; malignant
disease; sickle cell disease and sickle cell trait are
relative contraindications.
• Reinfusion of salvaged blood which has been shed for
more than 6 hrs: the transfusion is likely to be harmful
since there will be hemolysis of red cells, hyperkalemia
and a risk of bacterial contamination.
Advantages
• Acceptable to some Jehovah’s witnesses.
• Cost effective with large volume losses. However,
where Automated Suction Collection Systems (ASCS)
are used for cell salvage, the limitations include the
high capital cost of this equipment, significant cost of
disposable items for each patient and the presence of
a dedicated operator of the device.1,19
Use of blood analogues
Driven by a possible shortage of human donor
blood and other limitations of autologous blood transfusion,
452
artificial blood was developed during the last decades as
either :
• Cell - free purified haemoglobin solutions (for e.g.
recombinant or outdated human blood) – bind oxygen
similar to the erythrocyte p50, but variability may
occur among products (e.g., p50: 18 to 30).
• Perfluorocarbon emulsions (hydrocarbons with
fluorine or bromide substitution of hydrogen).
Advantages
a. They carry dissolved oxygen (also CO2 and N2) better
than plasma and require high inspired oxygen fraction
values.
b. PFC’s are not metabolized in biological systems,
temporarily stored in RES and exhaled completely
unchanged.
c. Adverse effects (fever and liver enzyme elevation ,
anaphylaxis to the emulsifier, modest coagulation
impairment) are mild and transient in humans in
clinical doses, but limit the use of PFC emulsions.20,21
Indications
Although the relative cost of these agents may limit
their widespread use, they may be useful when :
• Blood is not easily available (e.g., patients with
multiple antibodies) or accepted (Jehovah’s witness).
• Universal compatibility and prolonged shelf life and
transportability into the field (e.g., trauma, military).
• They may also have a place in settings where they
would enhance blood conservation techniques (e.g.,
normovolemic hemodilution).
Oxygen carriers are in the phase III trials as blood
substitutes, but current investigations indicate their potency
in a variety of other clinical applications. This includes the
reduction of gaseous microemboli during extracorporeal
circulation, improved oxygen delivery to ischaemic tissues,
enhancing tumour sensitivity to cancer therapy, organ
preservation in transplantation medicine and more.
In order to reduce morbidity associated with
transfusion, several measures have been advocated to reduce
operative blood loss. These include:
a. Improvement in surgical technique by attending to
bleeding points, using diathermy, using local
haemostatic agents whenever necessary
b. Posture of the patient
c. Use of vasoconstrictors
d. Use of tourniquets wherever applicable
INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2004
e. Improved anaesthetic technique by
- Preventing episodes of hypertension and tachycardia
- Avoiding hypercarbia
- Using regional anaesthesia, where appropriate
- Hypotensive Anaesthesia
f. Use of antifibrinolytic and other drugs where
appropriate
Blood and blood component administration in
patients with excessive perioperative bleeding is generally
empiric because turnaround times of laboratory - based
tests are too long.22 This accounts for a large part of the
widespread prophylactic administration of blood
components.23,24,25 Recently published transfusion guidelines2
suggest that hematologic profiles (e.g. hematocrit,
prothrombin time, activated partial thromboplastin time,
fibrinogen) be available in a reasonable amount of time to
guide effective and optimal management of patients with
perioperative anaemia and bleeding. Implementation of
point-of-care test methods would facilitate rapid acquisition
of critical results that would help clinicians optimize
transfusion and pharmacologically based management of
anemic or bleeding patients.
Conclusion
Transfusion of blood and blood products carries a
high risk of adverse reactions which may be life threatening.
Therefore it is imperative to follow the guidelines laid
down by the various organizations.
WHO prescribes all clinicians to go through a
checklist before prescribing blood1 :
a. What improvement in the patient’s clinical condition
am I aiming to achieve?
b. Can I minimize blood loss to reduce this patient’s
need for transfusion ?
c. Are there any other treatments I should give before
making the decision to transfuse, such as intravenous
replacement fluids and oxygen ?
d. What are the specific clinical or laboratory indications
for transfusion for this patient?
e. What are the risks of transmitting HIV, hepatitis,
syphilis or other infectious agents through the blood
products that are available for this patient?
f. Do the benefits of transfusion outweigh the risks for
this particular patient?
g. What other options are there if no blood is available
in time?
AHUJA, MOTIANI : ISSUES IN TRANSFUSION PRACTICE
h. Will a trained person monitor this patient and respond
immediately if any acute transfusion reactions occur?
i. Have I recorded my decision and reasons for transfusion
on the patient’s chart and the blood request form?
Judicious use of the optimum blood component - only
when indicated, in proper dosage, and with appropriate
follow up studies can lead to better transfusion practices.
This should decrease morbidity and provide optimal patient
care.
References
1. World Health Organization. Handbook on The Clinical use of
Blood. WHO. Blood Transfusion Safety. Geneva 2001.
2. Practice Guidelines for Blood Component Therapy. A
Report by the American Society of Anesthesiologists Task
Force on Blood Component Therapy. Anesthesiology 1996;
84: 732-47.
3. American College of Physicians : Practice strategies for elective
red blood cell transfusion. Ann Intern Med 1992; 116: 403-06.
4. Development Task Force of the College of American Pathologists.
Practice parameter for the use of fresh frozen plasma,
cryoprecipitate and platelets. J Am Med Assoc. 1994; 271:
777-781.
5. Greenwalt TJ, Perry S. Preservation and utilization of the
components of human blood, In: Progress in hematology,
edited by Brown EB and Moore CV, Grune and Stratton,
New York, 1969; 157.
6. Moss GS, Proctor HJ, Homer LD et al. Comparison of
asanguineous fluids and whole blood in treatment of
hemorrhagic shock. Surg Gynecol Obstet 1969; 129: 1247.
7. Reece RL, Beckett RS. Epidemiology of single-unit transfusion:
a one-year experience in a community hospital. JAMA 1965;
195: 801.
8. Allen JG. The case for the single transfusion. N Engl J Med
1972; 287: 984.
9. Cass RM, Blumberg N. Single-unit blood transfusion: doubtful
dogma defeated. JAMA 1987; 257: 628.
10. Levine E, Rosen A, Sehgal L et al. Physiologic effects of acute
anaemia: implications for a reduced transfusion trigger.
Transfusion 1990; 30: 11-14.
11. Wilkerson DK, Rosen AL, Gould SA et al. Oxygen extraction
ratio: a valid indicator of myocardial metabolism in anemia.
J Surg Res 1987; 42: 629-634.
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12. Levy PS, Chavez RP, Crystal GJ et al. Oxygen extraction
ratio : a valid indicator of transfusion need in limited coronary
vascular reserve? J Trauma 1992; 32: 769-774.
13. Shah DM, Gottlieb M, Rahm R et al. Failure of red cell
transfusions to increase oxygen transport or mixed venous
pO2 in injured patients. J Trauma 1982; 22: 741-746.
14. Schiffer CA, Anderson KC, Bennet CL et al. Platelet transfusion
for patients with cancer: Clinical practice guidelines of the
American Society of Clinical Oncology. Journal of Clinical
Oncology 2001; 19: 1519-1538.
15. Meryman HT, Hornblower M. The preparation of red cells
depleted of leukocytes: review and evaluation. Transfusion
1986; 26: 101.
16. British Committee for Standards in Haematology (1996)
Guidelines on gamma irradiation of blood components for the
prevention of transfusion-associated graft-versus-host disease.
Transfusion Medicine; 6: 261-271.
17. Soni N, Margarson M. The human albumin controversy.
Recent Advances in Anaesthesia and Analgesia 21: 127-138.
18. Linden JV, Kaplan HS, Murphy MT. Fatal air embolism
due to perioperative blood recovery. Anesth Analg 1997; 84:
422-426.
19. Napier JAF, Bruce M, Chapman J et al. British Committee
for Standards in Haematology Blood Transfusion Task Force.
Guidelines for autologous transfusion. II. Perioperative
haemodilution and cell salvage. Br J Anaesth 1997; 78: 768-71.
20. Frietsch T, Lenz C et al. Artificial blood. Recent Advances in
Anaesthesia and Analgesia 21: 103-126.
21. Despotis GJ, Goodnough LT. Current and Evolving Issues in
Transfusion Therapy. The American Society of Anaesthesiologists
29; 10: 97-111.
22. Ellison N, Jobes DR. Effective Hemostasis in the Cardiac
Surgical Patient: Current Status. Effective Hemostasis in
Cardiac Surgery. Edited by Ellison N, Jobes DR. Philadelphia,
Saunders, 1988; 200.
23. Goodnough LT, Johnston MF, Toy PT. The variability of
transfusion practice in coronary artery bypass surgery.
Transfusion Medicine Academic Award Group. JAMA 1991;
265: 86-90.
24. Simon TL, Aki BF, Murphy W. Controlled trial of routine
administration of platelet concentrates in cardiopulmonary
bypass surgery. Ann Thorac Surg 1984; 37: 359-64.
25. Milam JD, Austin SF, Martin RF, Keats AS, Cooley DA.
Alteration of coagulation and selected clinical parameters in
patients undergoing open heart surgery without transfusions.
Am J Clin Pathol 1981; 76: 155-62.
– Editor