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Blood Transfusion

Ruli Herman S dr, SpAN

Department of Anesthesiology School of Medicine, Padjadjaran University/ Hasan Sadikin General Hospital Bandung

Blood transfusion : Memindahkan darah/komponen donor ke pasien darah dari

Tujuannnya - Memperbaiki kadar Hb Untuk meningkatkan penyampaian Oksigen (DO2) - Memperbaiki Mekanisme Koagulasi Cautions : - Appropriate indications - Appropriate techniques - Observations of sign of complications - Prevention and therapy for complications

INDIKASI - Transfusi sering diberikan pada pend. Anemia Anemia Meningkatkan risiko kesakitan dan kematian : Pend. Dg kelainan jantung dan paru

Transfusi darah sendiri mempunyai risiko : Herbert dkk : Pasien yang mendapat Trans. Sp Hb 10-12 g/dl angka kematian lebih tinggi dibandingkan dg target Hb 7g/dl

Transfusi hanya dilakukan jika ada bukti gangguan oksigenasi jaringan atau adanya hiperlaktatemia ASA Nilai Hb 6 8 g/dl pasien tanpa risiko Nilai Hb 10 11 g/dl pada pasien dengan risiko iskemia Nilai 7 10 g/dl pasien dg risiko Nilai > 10 g/dl untuk pasien sepsis.

Morita tidak ada perbedaan nilai kritis Hb pada pasien sepsis.

RISIKO TRANSFUSI. 1. Tidak Efektifnya oksigenasi jaringan karena usia darah yang ditransfusikan terlalu lama. - Terjadi penurunan ATP dan 2,3-diphosphogliserat meningkatkan afinitas hemoglobin terhadap Oksigen. - meningkatkan risiko inf. Nosokomial

2. Perubahan Immunitas.

- Peningkatan rekurensi keganasan - infeksi pasca bedah penurunan fungsi makrofag dan Sel T setelah transfusi.
3. Risiko penularan penyakit infeksi. - Hepatitis C virus - HIV - Malaria dll.

4. Risiko lainnya. A. Reaksi Hemolitik. - Akibat kesalahan administrasi. - Demam, menggigil, mual dan nyeri dada sp kepinggang Kematian jika transf. tidak segera distop. - 1 : 250.000 s/d 1.000.000 B. ARDS - sesak, hipotensi, demam dan edema paru non kardiak - 1 : 50.000

C. Reaksi anafilaktik Hipotensi - 1 : 15.000 - Reaksi berat yang dapat terjadi hanya dengan sedikit darah - Pasien dengan defisiensi Ig A dg antibody anti IgA - Epineprin, cairan dan kortiko steroid.

Type of Blood/Blood Component for transfusion

1. Whole Blood
* Fresh Blood, storing time 4-6 hours advantages : - complete caogulation factors - good blood cell functions disanvantages : - impractical supply - risk of infections transmission i.e lues, CMV

* New blood, storing time 3-4 days advantages : - easy suppliyng disadvantages : - coagulation factors, especially factor V and VIII almost depleted ( high Hb affinity to O2 decreased O2 release from Hb to tissue) + - High concentration of K , amonium and lactic acid

2. Red blood cell

advantages : a. plasma is not given. Avoid circulation overload b. hematocrit level could be tailored c. hepatitis (infections) hazard avoided d. advantages in patients with renal disease e. allergic reactions decreased f. autoimmun bodies reactions decreased g. anticoagulant free disadvantages : a. possible infections hazard during preparation b. short storing period, 4-6 hours.

Packed Red Cell - made by separating/extracting plasma in close methode until hematocrit level 70 80 % Red Cell Suspensions - made by mixing RBCs concentrate with solvent on equal volume Washed Red Cell - made by washing RBC concentrate 2-3 times with physiologic NaCl solution : a. PNH (Paroxysmal Nocturnal Hb-uria) b. Acquired Haemolytic Anemia c. Exchange transfusion d. Transfusion on renal transplant.

3. Thrombocyt
given to patients with thrombocyt deficits due to primary disease or secondary due to bleeding. Type of thrombocyt : 1. Platelet Rich Plasma (PRP) PRP made by separating plasma from fresh blood 2. Platelets Concentrate Made by centrifuging PRP and separating its thrombocyt concentrate Storing : a. In 40 Celcius - good haemostatic, short life span b. In 180 Celcius - poor hemostatic, better life span Storing time 48 72 hours

4. Plasma
a. restore blood volume and circulation b. replace and enhance blood proteins c. replace and improve spesific plasma factor * Liquid plasma made by separating plasma from whole blood on packed red cell preparation process * Dry plasma made by drying liquid plasma Advantages : - long storing time (3 years) - easy transport - room temperature storage - no risk of lues infections - independent of blood group Disadvantages : - higher risk of hepatitis infection due to collected from various donors.

* Fresh Frozen Plasma made by separating plasma from fresh whole blood and immediately freezed at minus 600 Celcius (CO2 ice) storage : - at temp. minus 300 C for 1 year - at temp. minus 200 C for 6 months ideally given on : - bleeding cases - as fresh whole bood replacement if mixed with packed red cell

* Cryoprecipitate
made by freezing fresh frozen plasma at minus 600 C and liquified at 4-6 C advantages : contains much amount of factor VIII and factor I (fibrinogen). A bag of cryoprecipitate contains 130 units of Anti Hemophylic Factor (AHF)

Complications of Transfusion
1. Hemolytic Reaction Red blood cell destructions occur producing free Hb in plasma due to blood group incompatibility. If free Hb level more than 25 %, Hb uria occur. Acute : -occur immediately when transfusion. 50 cc of incompatible blood enough to precipitate the reactions

sign : - hot sensation along the veins - specific lumbal pain - depressed chest feeling, dyspneu - headache, flushing face - raised body temp., nausea & vomitting - during anesthesia : tachypneu, hypotension, small pulse pressure, shock. Diffuse bleeding from operative wound. Laboratory : - Hb-uria - Peripheral blood preparate hemolytic sign - Blood bilirubine - Free Hb in plasma - methemoglobine

Delayed : Occur on patients who recieved frequent transfusion or women who previously had delivered baby. Reactions occur after several hours or days after transfusion and commonly after transfusion of second bag or more.

Therapy : stop transfusion, change transfusion set treat shock shock position plasma expander infusion vasopressor sodium bicarbonate oxygenation lasix / 20 % manitol corticosteroids report to blood bank * send back transfused blood * send sample of patients blood * patients urine - control Hb level * thrombocyt * fibrinogen - give compatible fresh blood

2. Non Hemolytic Reactions 1. Allergy - antigen in donors blood will bound with its antibody in recipients serum - antibody which present in donors blood which passively transfered by transfusion to recipient therapy : give antihistamine and corticosteroid on severe reactions.

2. Pyrogen reactions
sign : - febrile (38-400 C) - shivering, headache, pain on the whole body, restless untill convulsions

3. Bacterial containation reactions

- bacterial contamination collecting. could occur during blood

Sign : - febrile, headache, shivering, vomitting, stomachache, diarrhea to shock. These sign occur during or immediately after transfusion Therapy : - stop transfusion - treat shock (plasma expander, vasopressor, oxygen etc)

4. Overload
occur due to transfusion of relatively too high volume in a short period. For these reason, whole blood should be given cautiously on some circumstances : - anemia - decreased cardiac reserve - renal disease - oedema

sign : - headache, precardial pain, coughing, dyspneu, heavy feeling on both arms, pulmonary rhales and elevated neck veins therapy : For patients with overloading tendency : - Infusion drips as slow as possible (adult 12-30 drips/min, children 6-8 drips/min) - diuretics before transfusion - only blood component is given - close observation during transfusion

5. Heart rhythm disturbances

mostly occur on rapid and massive transfusion of : - cold blood - elevated K+ level - citrate toxicity general therapy : - slowing transfusion rate specific therapy: - blood heated to body temperature - better if switch to fresh blood

6. Acidosis
On patients with acidosis tendency (i.e. renal failure, ileus, septic conditions) administering stored blood will worsening those condition, so did massive transfusion. Therapy : -correction of acidosis with sodium bicarbonate

7. Kalium toxicity
due to elevated K+ level in blood which stored more than 10 days sign: - ECG changes - Cardiac arrest danger Prevention : - administer fresh blood therapy : - enforce diuresis - Glucose 5 % infusion + regular insuline 8-12 units

8. Citrate toxicity
especially on massive transfusion (>2 liters) on patients with poor hepatic function, where citrate will bound to Ca++ ion. Sign : - tetany, tremor, ECG disturbances to cardiac arrest therapy : - Ca gluconate i.v or CaCl2 1 gram every 1000 ml of blood transfused

9. Coagulation disorder
especially on massive transfusion with stored blood, due to reduced thrombocyt and other coagulation factors. Therapy : - administering 1 unit of FFP or cryoprecipitate for every 5 unit of whole blood.

10. Hyperammonium
- amonium blood level increase after 5-7 days and reach maximal level after 3 weeks of storage therapy : - administering fresh blood.

11. Air embolism

due to technical error, especially on transfusion with pressured bag therapy : - positioning the patient laterally to cardiac side - shock positioning

12. Transmission of disease

* Hepatitis sign & symptoms appear 2-3 months after transfusion sign : icterus, hepatomegaly, spleenomegaly therapy : -immuniglobuline, diet to improve hepatic functions prevention : Donor is not accepted before 5 years of convalescence period

* Malaria sign appear after 1-10 days afer transfusion prevention : Donor is not accepted under 2 years from last attack. therapy : - antimalarial drugs * Syphylis sign appear 9-10 weeks post transfusion and manifest as stage II skin lesions.

Methods for estimating blood loss

1. Measuring Gauzes Weight Blood loss equal to gauze weight difference before and after used (1 gram equal to 1 ml blood) 2. Calori meter Used gauze washed with standardized water and ammonium 3. Visual Estimation Could be done by an experts. Blood clot of a fist size equal to about liter of blood. 4. Measuring blood on suction apparatus Sometimes difficult due to other liquid mixing or suction rinsing with water. 5. Patients clinical conditions Difficult due to anesthetic drug alter clinical response to bleeding

Transfusion techniques
1. Infusion set preparation Infus set must be equipped with filter Infusion needle gauge should be appropriate to intended rate of transfusion a. easily damage venous wall, causing swollen tissue b. commonly use on babies,easy fixation c. plastic catheter with stylet inside, if already inserted, will not damage the vein easily

3. Inserting infusion set

a. notify the patient if an infusion will be inserted b. If possoble, choose a large- straight vein which not locate on ajoint c. Stagnate the vein d. Do not attemp/reattemp on acollapsed vein e. Fixation Better if on three locations - on the root of the catheter - on rubber plastic junction - on transparant plastic hose f. Use splint g. On emergency conditions could inserted > 1 infusion h. Build patients cooperation, on conscious patients i. on emergency condition j. all procedure must be done under sterile conditions

3. Blood bag preparation

a. Must be carefull ! patients identity, blood group, cross-match result, bag label number, blood plasma colour, any blood clot b. Do not shake blood bag c. Before transfused, blood should be warmed d. Blood must keep refrigerated before use e. Blood bag which already perforated, must immediately transfused

4. On transfusing blood
a. Note! Blood pressure, heart rate, respiration and patinets temperature b. Before transfusing blood, give NaCl infusion c. If blood drips stagnant, change transfusion set d. During first 15 minutes, patients should be carefully monitored e. During transfusion, blood pressure & respiration must be monitored

5. Rate of transfusion
a. On massive bleeding, administer blood as fast as possible (1500 ml in 15 minutes) b. On normovolemic patients : adult : 500 ml / 5-6 hours children : depend on body weight and age

6. Tricks for enhancing blood transfusion

a. b. c. d. Put blood bag as high as possible Insert big bore catheter Give pressure to blood bag Injecting blood on the catheter

Prinsip Umum 1. Transfusi harus mempertimbangkan keuntungan serta kerugian transfusi. 2. Pasien harus diberitahu risiko dan keuntungan transfusi. Pasien berhak menolak. 3. Penyebab anemia harus diketahui. 4. Tidak ada nilai Hb tertentu dimana pasien harus ditranfusi. Keadaan klinis lebih penting untuk memberikan atau tidaknya transfusi

5. Pada kehilangan darah akut, penggantian cairan tubuh dengan kristaloid dan koloid segera dilakukan. Efek anemia harus dibedakan dari efek hipovolemia. 6. Alasan transfusi harus ditulis dalam catatan medik.