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Blood Transfusion
Transfusion of blood and blood products

One of the most important advances in surgery has been the availability of blood and other blood products. Without the ability to safely give blood during many of the complex surgical procedures that have saved countless lives, these procedures would not have succeeded.

  • Blood Donation, Collecting and Processing (American Red Cross)
  • Blood donors are healthy volunteers usually over the age of 17 years and at least 110 pounds in weight. Each donor is initially screened through a detailed medical history
  • The blood is processed into its various parts such as red blood cells, platelets and plasma (see below)
  • Every unit of blood is tested for
    1. Antibodies to HIV-1 and HIV-2 (AIDS). An antibody is protein in the blood produced by the body in response to a foreign protein (antigen) such as the AIDS virus
    2. Antibodies to HBc produced during and after infection with Hepatitis B Virus
    3. Antibodies to HCV produced after infection with the Hepatitis C virus
    4. Antibodies to HTLV-I/II produced after infection with Human T-Lymphotropic Virus (HTLV-I and HTLV-II)
    5. Antibodies to HBsAg produced after infection with Hepatitis B
    6. HIV-1 p24, a test for the HIV (AIDS) antigen
    7. For blood type (ABO) and Rh factor
    8. Tp, the agent that causes syphilis
    9. ALT, an elevated ALT may indicate liver inflammation, which may be caused by a hepatitis virus
    10. The presence of unexpected antibodies that may cause reactions after the transfusion
    11. CMV, a test for the cytomegalovirus (performed on physician request)
    12. NAT (Nucleic Acid Testing) - a new technology that can detect the genetic material of Hepatitis C and HIV. This test, which is still under investigation, has the potential to identify these viruses faster and more accurately
  • About 70% of the blood products are filtered to remove leukocytes (white blood cell) that fight foreign material such as bacteria, viruses and abnormal cells that may cause disease. When leukocytes are present in donated blood, they may not be tolerated by the person receiving the blood and cause some types of transfusion complications
  • The various blood components are labeled as to blood type and Rh factor (O+, A+, B+, AB+, O-, A-, B-, AB-) Figures 1 and 2

Figure 1 - Reagents used for determining blood types A, B and O as well as the Rh factor.

Figure 2 - Bag of packed red blood cells.

  • The blood products are stored at their appropriate temperature
  • The blood products are delivered to the hospitals as needed
  • At the hospital, the blood products are cross-matched with the patients' blood
  • The blood products are transfused as needed by the patient. A needle is placed in the patient's vein and the blood product given into the vein. The doctor determines the type and amount of the blood or blood product that is transfused based on the patient's needs (Figure 3)

Figure 3 - Patient receiving a transfusion of PRBC's

Blood Products and Their Indications for Transfusion

  • Allogenic Red Blood Cells or PRBCs (Packed Red Blood Cells). (Figure 2) Transfusion of PRBCs is based on an evaluation of on going blood loss, symptoms of anemia, cardiovascular (heart and blood vessel) status and an assessment of the present and possible future cardiovascular stress. There is no single "transfusion trigger" such as the level of hemoglobin in the blood (hemoglobin is the material in the red blood cells (RBCs) that carries oxygen to the body tissues
    1. RBC's are transfused to increase or maintain the capacity of blood to carry oxygen and not to promote wound healing or a general sense of well-being
    2. The signs and symptoms, which may require transfusion in a patient with a normal blood volume (normovolemic) patients, include syncope (passing out), dyspnea (shortness of breath), postural hyoptension (giddiness when standing up), tachycardia (fast heart rate), angina (chest pain from heart disease) and transient ischemic attack (minor stroke)
    3. Patients at risk for cardiovascular (heart vessel) or cerebrovascular (brain vessel) problems include those with coronary artery disease, valvular heart disease, congestive heart failure, cerebrovascular disease, a history of transient ischemic attacks or stroke and other risk factors such as a history of smoking, hypercholesterolemia (high blood cholesterol), etc
    4. Healthy adults at low risk for cardiovascular or cerebrovascular disease can tolerate very low levels of hemoglobin without bad affect. Transfusion, even for a level of hemoglobin less than 8 (gm/100 cc of blood), may not be indicated. Patients with hemoglobin >10 rarely require transfusion, even those at risk for cardiovascular or cerebrovascular events
  • Fresh Frozen Plasma. Fresh frozen plasma (FFP) is given to correct coagulation factors and plasma protein deficiencies. (Figure 4)

Figure 4 - Bag of fresh frozen plasma

    1. FFP is given when there is a significant blood coagulation (clotting) abnormality and either evidence of ongoing bleeding or the need to perform surgery
    • Urgent reversal of warfarin anticoagulation (blood thinning). Warfarin (Coumadin┬«) blocks the formation of the blood clotting factor, prothrombin, by the liver. Vitamin K is necessary for blood clotting. Warfarin is used as a blood thinner to prevent heart attack and stroke and in some rat poisons
    • Correction of known blood clotting factor deficiencies for which specific concentrates are not available
    • In liver disease or urgent correction of a low blood vitamin K
    • Bleeding from small vessels in the presence of a low level of prothrombin or when a large number of PRBC transfusions are given
    1. Plasma exchange in patients with Thrombotic Thrombocytopenic Purpura
    2. Given in certain plasma protein deficiencies for which a specific concentrate is not available, e.g. Protein C or Protein S deficiency
    3. The more aggressive correction of certain blood clotting factor deficiencies in patients with bleeding in the brain, spinal cord or eye or in patients with associated poor platelet function
  • Platelet Concentrates. Platelets are cells smaller than a red cell and are necessary for blood clotting. Platelet transfusions are given to prevent or control bleeding when the number platelet are low or the clotting ability of the platelets is poor (Figure 5)

Figure 5 - Bag of platelets

    1. Platelet concentrate may be given to prevent bleeding when the platelet count is less than10,000/uL without active bleeding
    2. Platelet concentrate may be given when the platelet count is less than 50,000/uL in patients scheduled for surgery
    3. Platelets may be given in patients having brain or spinal cord surgery or cardiovascular surgery if the platelet count is less than 100,000/uL and there evidence of above average bleeding
    4. May be given when there is active bleeding in a patient with a platelet count of less than 50,000/uL or active bleeding in a patient with poor functioning platelets
  • Cryoprecipitate. Cryoprecipitate is generally used to replace blood clotting factors (Factor VIII, fibrinogen, or Factor XIII)
    1. Low blood fibrinogen may be documented by the presence of active bleeding or a blood fibrinogen concentration of less that 100 mg/100cc
    2. Cryoprecipitate may be used to make up "Fibrin Glue" that is applied to the surface of tissues to stop certain types of bleeding
    3. May be used in Von Willebrand's Disease (in which certain blood clotting factors are missing) when specific factor concentrate for the disease is not available and there is active bleeding or the patient requires surgery
  • Other blood products are available but are usually not used in surgery
  • Pre-Deposit Autologous Blood. This is blood that has been deposited by the patient several weeks before the planned surgery. Collection and transfusion of pre-deposit autologous blood are not totally free of hazard. A person may become anemic after donation and there is a risk of heart attack or stroke if the donor has undetected vascular disease or heart disease. Rarely clerical errors may occur with the possibility of transfusing the wrong unit of blood. Bacterial contamination of the unit may also occur
  • Directed Donor Blood. This is blood that has been deposited by individuals known to the patient, the patient's family or friends. Directed Donor Blood may be transfused according to the same criteria as donor blood (see indications for red blood cell transfusions). Except that the donor is known, this type of donation has the same risks as any other donor's blood

The Risks of Transfusion

With every benefit of treatment in medicine there is the necessity to be aware of unwanted risks. With blood product transfusion the patient must understand the risks:

  • Disease transmission, particularly AIDS, Hepatitis C and bacterial infection. This is quite uncommon
  • Allergic or other reaction to the blood
    1. Minor and temporary reactions, which are not uncommon, such as bruising, swelling or infection where the needle enters the skin
    2. Minor reactions to the transfusion may include headache, chills, fever or skin reactions such as itching, rash or hives. Other unusual minor reactions may also occur
    3. More serious reactions are also possible though less likely such as an overload of fluid, lung failure or death
  • Transfusion of the wrong type of blood occurs rarely and can cause death
  • Incidence of risk per unit transfused is as follows:

Transfusion Associated Disease

Risk / Tested Unit

Transfusion of red cells to wrong patient

1/12,000 – 1/19,000

Infection from unit of platelets

1/15,000

Transfusion of pre-deposited blood to wrong

   patient

1/16,000 – 1/25,000

ABO incompatible transfusion

1/33,000 – 1/38,000

HTLV

1/641,000

Hepatitis B

1/140,000

Hepatitis C

1/225,000 (without NAT testing)
1/790,000 - 1/1,600,000 (with NAT testing)

ABO incompatible related death

1/600,000

HIV

1/1,300,000 (without NAT testing)

1/1,900,000 (with NAT testing)

Hepatitis A

1/1,000,000

Bacterial contamination of red blood cells

1/1,000,000

Malaria

1/1,000.000

Syphilis

1/1,000.000

The Risks of Refusing Transfusion

  • The patient must understand that he or she may refuse blood or blood product transfusion whether it is for religious or other reasons even though this may lead to complications and death
  • Blood is essential for the body to function properly and for life. It may be impossible to use an alternative to blood and/or blood products since at this time there is NO EFFECTIVE ALTERNATIVE TO A TRANSFUSION
  • If patients do not have enough blood or critical blood components, they may go into shock or a coma and/or suffer very serious harm or even death. In these situations there is NO EFFECTIVE ALTERNATIVE TO A TRANSFUSION
  • The alternatives to blood or blood products consist of attempting to limit the loss of blood as much as possible, something a surgeon already does, and using blood volume expanders such as saline and Dextran. This, however, may lead to severe anemia, difficulty with the clotting of blood and even death