BLOOD TRANSFUSION

S. Sunatrio
Department of Anesthesiology, Faculty of Medicine,
University of Indonesia/Cipto Mangunkusumo Hospital,
Jakarta - Indonesia
What can be still encountered in
the daily clinical practice

Transfusion is performed merely

because the blood has been already
available
Transfusion to reach Hb 10g/dL to
promote wound healing
Whole blood is still ordered instead
of blood component
What can be still encountered in
the daily clinical practice
Fresh blood sometimes ordered
Transfusion to reach Hb 10g/dL
perioperatively as a minimal Hb level
for every pt
FFP/albumin is given as a nutrient.
FFP is given without evidence of blood
coagulation disorder or as plasma
substitute
Blood transfusion

important part of modern medical service

can be life saving
improve health care
WHO recommendation (1998):
Developing a National Policy and
Guidelines on the Clinical use of Blood .
Problems of transfusion

is performed based on appropriate

clinical & lab assessment
can be associated with complication,
risk of transmission of disease,
immunosuppression
National policy on the use of blood
transfusion
 Problems with Blood
Disease
Biochemical abnormalities:
Hypernatremia
Acidosis
Hyperkalemia
Hypocalcaemia
Delayed effects:
Metabolic alkalosis
Hypokalemia
Immunomodulation
 Problems with allogeneic transf

Still assoc with risks (haemolysis,

infection & immunosuppression)
Postop wound infection
Recurrence rate of malignancy
Unnecessary over-transf mortality in
cardiac risk pts
blood product cost
 Transfusion Fatalities (2001-
2002) in the United States*

Bacterial 17
Contamination

TRALI 16
(transfusion related
acute lung injury)
Mistransfusion ABO 14
mismatch

*From the FDA (Oct 1, 2001 to Sept 30, 2002)

 To control the immunological
risk & costs
Allogeneic transf completely avoided
Minimized during op
Intraop transf of autologous blood collected
preop (autolog blood donation, ANH) or
intraop blood salvage
blood loss (skillful surg technique, deliberate
hypotension, adm of antifibrinolytic drug)
Tolerance of low Hb level
JAMA
Relationship of blood transfusion & clinical outcomes
in patients with acute coronary syndromes
Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong
PW, Moliterno DJ, Lindbald L, Pieper K, Topol EJ, Stamler JS, Califf
RM. Jama 2004 Oct 6;292(13):1555-62

Conclusions : Blood transfusion in the setting of

acute coronary syndromes is associated with higher
mortality, and this relationship persist after
adjustment for other predictive factors and timing of
events. Given the limitations of post hoc analysis of
clinical trials data, a randomized trial of transfusion
strategies is warranted to resolve the disparity in
results between our study and other observational
studies. We suggest caution regarding the routine
use of blood transfusion to maintain arbitary
hematocrit levels in stable patients with ischemic
heart disease.
WHO principles for the clinical use
of blood components [WHO (1998a)]
Transfusion is only one element of the pt`s
management
Prescribing decisions should be based on the
national guidelines on the clinical use of blood
components, taking individual pt needs into
account
Blood loss should be minimised to reduce the pt`s
need for transfusion
The pt with acute blood loss should receive
effective resuscitation (iv replacement fluids, O2 etc)
while the need for transfusion is being assessed
 WHO principles for the clinical use
of blood components [WHO (1998a)]
The pt`s Hb level, although important, should not be
the sole deciding factor in starting transfusion. The
decision to transfuse should be supported by the need
to relieve clinical signs & symptoms & prevent
significant morbidity & mortality
The clinician should be aware of the risks of
transfusion-transmissible infection in the blood
components that are available for the individual pt**

** It should be noted that the rates of non-infective complications are

probably higher than those of infective complication
WHO principles for the clinical use
of blood components [WHO (1998a)]

Transfusion should be prescribed only when

the benefits to the pt are likely to outweigh
the risks
The clinician should record the reason for
transfusion clearly
A trained person should monitor the
transfused pt & respond immediately if any
adverse effects occur
 Panelist
1.Prof DR Dr Eddy Rahardjo,
HTA unit SpAnKIC
Ministery of Health RI 2.Dr S Sunatrio, SpAnKIC
1.Prof DR Dr Sudigdo 3.DR Dr Iqbal Mustafa, SpAnKIC,
Sastroasmoro, SpA(K) FCCM
4.Prof DR Dr Moeslichan Mz,
2.DR Dr Iqbal Mustafa, SpA(K)
SpAnKIC, FCCM
5.Dr Djajadiman Gatot, SpA(K)
3.Dr Ratna Mardiati, SpKJ 6.Dr Ali Sungkar, SpOG
4.Dr Wuwuh Utami, MKes 7.Dr Suzanna Immanuel, SpPK
5.Drg Rarit Gempari, MARS
6.Dr Frida Soesanti Contributor
7.Dr Nila Kusumasari 1.Dr Djumhana Atmakusuma,
SpPD, KHOM
2.Dr Gunawarman Basuki,
SpAn(K)
Variation in the design & quality of the
studies consistent results (level 1 evidence)

Threshold level for transf RBC is considerably lower

than historical threshold (Hb 10g%, Ht 30%)
No adverse outcomes if restrictive transf thresholds
are used rather than liberal strategies & there is some
evidence to suggest that restrictive strategies may
reduce all-cause mortality & LOS in the hospital as
well as transf related complications
Restrictive transf thresholds also reduce the amount
of RBC that are transfused
Acute anemia: loss of 50% BV is
tolerable in the absence of
hypovolemia, severe heart or
pulmonary disease
Hypovolemia 30% is tolerable
BW 70 kg Hb 15 g %
Normal basal O2 demand = 280 mL

Oxygen transport = CO x (sat O2 x Hb x 1,34 + pO2 x 0,003)

= 5 L/min x 20 mL O2/100mL
= 1 L O2/min
Hb 10 g% = 5 L/min x 14 mL O2/100mL
= 700 ml O2/min
Hb 5 g% = 15 L/min x 6,6 mL O2/100mL
= 1 L O2/min
 HEMATOCRIT
%
NORMAL
OPTIMAL
40 TOLERABLE

30

20

0
HTA: Transfusion of RBC
(A recom)

If Hb <7g/dL almost always

indicated
might be postponed if there is no
obvious symptom of hypoxia
might be postponed if the pt needs
another specific th/ erythropoietin
/EPO lower Hb level can be
tolerated
RCT:
Hb 7-9 g/dL & Hb 10-12 g/dL did not
differ in morbidity & mortality
Russell JA. Fluid Strategy in ARDS: The concept of maintaining
peripheral perfusion. In H Burchardi G, GJ Dobb, J Bion, RP Delinger
(eds) WB Saunders. London 1997p; 17-42.

Multi center study:

No improvement in morbidity &
mortality in pt who received
transfusion with Hb 8 g/dL - 10 g/dL
Carson JL et al. Perioperative blood transfusion and postoperative
mortality. JAMA. 1998; 279:199-205.
 HTA: Transfusion of RBC (C
recom)

If Hb 7 10 g/dL :
* the benefit of transfusion is not
clear
* transfusion can only be performed
if there is significant hypoxia or
hypoxemia
 HTA: Transfusion of RBC
(A recom)
If Hb 10g/dL no transfusion
unless the pt needs a higher O2
transport capacity :
* severe COPD
* severe ischemic heart disease
If RBC are given, reasons should
be well documented
HTA: Transfusion of RBC in
neonates (C recom)

Hb < 11 g/dL if symptom of hypoxia (+)

Hb < 7 g/dL if symptom of hypoxia (-)
Hb < 13 g/dL if the pt suffering from:
heart disease, pulmonary disease or pt
needs O2 supplementation
 FDA guidelines
RBC should not be given just for volume
expansion, for improvement of general sense
of well being, to accelerate wound healing or
as hematinic agent
Platelet should not be given for prophylaxis,
either after CPB or massive transfusion
FFP should not be used for volume
expansion, as nutritional supplement or for
prophylaxis, either after CPB or massive
transfusion
HTA: Transfusion of platelet
(C recom)

to overcome bleeding if platelet < 50,000/L

< 100,000/L : in case of diffuse
microvascular bleeding
as a prophylaxis in pt with platelet < 50,000
who is about to undergo surgery or another
invasive procedure or after massive
transfusion
Bleeding pt with impairment of platelet
function
 Indikasi transfusi trombosit
pada DHF

Dewasa: perdarahan nyata/ berat

diberikan sampai perdarahan berhenti
Anak: hanya pada perdarahan masif.
Dosis 0,2 g/kg/dosis

Pedoman Tatalaksana Klinis Infeksi Dengue Di Sarana Pelayanan Kesehatan 2005

HTA: FFP (C recom)
for replacement of fact IX deficiency &
coagulation inhibition factor
for immediate reversal of warfarin
effect in the presence of potentially
life threatening hemorrhage
bleeding pt with abnormal coagulation
parameter after massive transfusion or
CPB or with liver disease
HTA: Cryoprecipitate (C recom)

Prophylaxis in pt with fibrinogen

deficiency who is about to undergo
invasive procedure & th/ in pt with
hemorrhage
Pt with hemophyllia A or
von Willebrand`s disease who is
bleeding or unresponsive to acetate
dismopressin or who is about to
undergo surgery
HTA: Skrining donor darah yg
aman (rekom C)

Pemeriksaan harus secara individual,

jangan secara pooled plasma
Jenis pemeriksaan sesuai standard
WHO (sifilis, hepatitis B & C, HIV)
Metode tes: rapid test, automated test,
ELISA hanya bila sensitivitasnya
>99%
 American Red Cross 2002
Indonesian
Red Cross 2002
1. Antibodies to HIV-1 and HIV-2.
2. HBc - antibody to HBV. 1. HIV
3. Antibody to HCV. 2. HBV
4. Antibodies to HTLV-I and HTLV-II. 3. HCV
5. HBsAg - Antigen test for HBV. 4. Syphilis
6. HIV-1 p24 Antigen test for HIV
7. Tp (Syphilis)
8. ALT liver inflammation,
9. Atypical antibodies US $ 200 vs $ 10
10. CMV - on request.
11. NAT (Nucleic Acid Testing) - for HCV & HIV
(faster and more accurate)
 ASA practice guidelines for
blood component therapy 1996
Recommendations: RBC

The task force concludes that:

transfusion is rarely indicated when the
Hb> 10g/dL & is almost always indicated
when it is < 6g/dL, especially when the
anemia is acute
the determination of whether intermediate
Hb (6-10 g/dL) justify or require RBC transf
should be based on the pts risk for
complications of inadequate oxygenation
SUMMARY
Prescribing RBC transfusion
requires clinical decision making
The lower limit or transfusion trigger for general
medical & surgical pts approximates Hb/Ht levels of
7.0g/dL & 21%, respectively. Below these levels,
morbidity & mortality increase
Some pt subsets, such as elderly pts suffering from
AMI, appear to have better outcomes when
transfusions increase the Ht to 30 to 33%
Current data suggest that restraining
transfusions favors positive pt outcomes-
except when significant underlying cardiac
disease is present
Do not tranfuse for following
reasons ! :

to improve general sense of well

being
as hematinic agent
to expand vascular volume
as prophylaxis if there is no risk
factor
Decision to transfuse RBC: Hb is
important but not the sole deciding factor

Sign & symptoms of hypoxia, ongoing

blood loss, the risk of anemia & the
risk of transfusion
Cardio pulmonary reserve
Volume of blood loss
O2 consumption
Atherosclerotic disease
Tolerable Hb level
No universal tolerable Hb level
Consideration must be made based on case by
case (co-morbidity)
Healthy young adult: tolerable Ht 20%
CRF : Ht 18 - 22%
Septic shock : Ht 30%
After severe shock : Ht 30 40%
CAD : Ht 35%
Severe COPD : Ht 40%
Blood management practice
guidelines for determining the
number of units of RBC (Spence 1995)

transfusion need should be assessed

on a case-by-case basis
blood should be transfused one unit at
a time, followed by an assessment of
benefit and further need
exposure to blood component should
be limited to appropriate need
It must be the responsibility of
all doctors to ensure that blood
component therapy is given
only when clearly indicated
(McGrath et al 2001)