BLOOD PRESERVATION IN CARDAIC SURGERY

1. RED BLOOD CELL AND
COMPONENT THERAPY
NIKHIL BANSAL

2. PATIENT BLOOD MANAGEMENT
THREE PILLARS OF CARE
• Preoperative: detect anemia
• Intra-operative: hemostais and cell salvage
• Post operative: optimization

3. WHY ?
One donated unit can help multiple patients
• Conserves resources
• Optimal method for transfusing large
amounts of a specific component

4. COMPONENTS
A blood component is a constituent of blood,
separated from whole blood, such as:
• Red cell concentrate
Plasma
Platelet concentrate
Cryoprecipitate, prepared from fresh frozen
plasma; rich in Factor VIII and fibrinogen

5. WHOLE BLOOD
• 450 mL whole blood in 63 mL
anticoagulant‐preservative solution
CONTENT
• Hb=1.2 g/dL, haematocrit (Hct)= 35‐45%
• No functional platelets or labile coagulation
factors (V and VIII )
STORED
+2°C to +6°C

6. WHOLE BLOOD cont..
Administration:
• NOT PREFFERED NOW

7. PRBC (PACKED RED BLOOD CELL)
• Red blood cells from which most of the
plasma has been removed
CONTENT
• Hb =20 g/100 mL (not <45 g per unit), Hct
55‐75%
STORED
• Stored at +2°C to +6°C

8. PRBC cont..
IN BAG
200ml of RBC+100ml optisol+30ml of plasma
DOSING
• Hb should be measured before and after every unit of RBCs
transfused
• Increase by 1g/dl, Hct by 3%
PAEDS
10ml/kg increase by 2g/dl
Satellite bags:50ml
5ml/kg bolus->1mg/kg furosemide->5ml/kg/hr

9. ADMINISTRATION
DISCUSSED LATER

10. INDICATIONS
Clinical signs and biochemical markers of inadequate oxygen
delivery
CLINICAL
• Tachycardia
• Hypotension
• Tachypnea or dyspnea
LAB
• Elevated blood lactate concentration (>2mmol/lt)
• Low pH (<7.2)
• Low central or mixed venous oxygen saturation (<60/50%)

11. INDICATIONS cont..
Signs of end-organ dysfunction
• Electrocardiographic (ST changes, onset of
arrhythmias) or echocardiographic indications of
myocardial ischemia
• Electroencephalographic indications of cerebral
hypoperfusion
• New onset oliguria (less than 0.5 mL/kg/h for >6 h)

12. TRANSFUSION TRIGGERS
• Hct <26%, no indication of transfusion if Hct
>30%
• Contains no clotting factors,so if >4-5units
required give FFPs also
Perioperative transfusion
• 8g/dL for patient undergoing cardiovascular
surgery
Chronic anaemia
• 7g/dL in adults

13. Processing Residual Circuit Whole
Blood
Three re-infusion methods
– Direct Ann Thorac Surg. 1993;56(4):938-43.
– Cell-Wash JECT. 1996;28(3):134-9.
– Ultrafiltration Perfusion. 2005;20(6):343-9.
Final Infusion Volume Contents
Technique
Volume cc
%
HCT
Plt Cnt
109/L
[Fib]
mg/dL
% Clot
Factors
Direct
700-1800+
17-25 50-140 80-135 15-40
Cell-wash
225-450
40-58 5-25 10-30 2-10
Ultrafiltration
450-1000
45-55 125-325 225-385 85-259

14. Ultrafiltration Versus Cell
Washing
Residual CPB Circuit Whole Blood
Issue Ultrafiltration Cell-Washing
Clotting factor preservation Concentrates remaining factors Discards clotting factors
Protein (fibrinogen) preservation Concentrates Albumin and Fibrinogen Discard albumin and fibrinogen
Allogeneic transfusion avoidance
Helps to avoid use of PRBCs and
component therapy
Helps to avoid use of PRBCs;
May increase the use of
component therapy
Heparin / drug removal Concentrates some drugs Removes many drugs
Platelet / RBC / WBC preservation Concentrates Functional Blood Cells
May waste or activate Platelets,
WBCs and RBCs
Interleukin / complement removal Removes some ILs complements
Removes some ILs or
complements
Contamination Should not introduce bacteria CW product contains bacteria
Fat removal May remove some fat Removes some fat
Cost-savings
Cost savings with decreased
allogeneic component therapy
Some cost savings with
reduced allogeneic PRBC use
1 Roeder. J Extra Corpor Technol. 2004;36(2):162-5.
2 Samolyk. Perfusion. 2005;20(6):343-9.
3 Jackson. J Extra Corpor Technol. 2006;38(1);A86.
4 Beckmann. J Extra Corpor Technol. 2007;39(2):103-8.
5 Riley. J Extra Corpor Technol. 2007;39(1)A3.

15. Platelet concentrates (PC)
• From pooled buffy coat-derived platelets from four whole blood
donations, suspended in platelet additive solution and the plasma
of one of the four donors
• As an adult therapeutic dose obtained from a single donor by
apheresis donation
CONTENT
• 50‐60 mL plasma that should contain ≥55 x 109 platelets
• Pooled unit, i.e. platelets prepared from 4‐6 donor units containing
at least 240 x 109 platelets
STORED
• Up to 5 days at +20°C to +24°C (with agitation)

16. PC cont..
IN BAG
250-350 ml
DOSING
• 1 unit of platelet concentrate/10 kg (6bags); for an adult of 60‐70 kg
• single donor units containing 8 x 109 platelets should raise the platelet
count by 7000-10,000
• Increment will be less if there is splenomegaly, disseminated intravascular
coagulation (DIC) or septicaemia
PAEDS
10-20ml/kg

17. PC cont..
Administration:
• After pooling should be infused as soon as possible because
of the risk of bacterial proliferation
• Over a period of not more than 30 minutes
• Do not give platelet concentrates prepared from RhD
positive donors to an RhD negative female with
childbearing potential
• ABO compatible, whenever possible (NOT OBLIGATORY)

18. INDICATIONS
• Platelet function defects and thrombocytopenia often occur after cardiac bypass
surgery/antiplatelet medication
• Platelet transfusion is recommended for patients with bleeding not due to
surgically correctable causes (closure time provides global indication of platelet
function)
• Prophylactic platelet transfusions are not required for all bypass procedures
NON BLEEDING: <20,000
BLEEDING: <100,000
Platelet function is impaired in hypofibrinigenemia and Hct <30%. So use PRBC and
cryo to bring Hct >30%
Should not be transfused within 6hrs of loading dose and within 4hrs of maintainance
dose of clopidogrel

19. Complications
• Febrile non‐haemolytic and allergic urticarial
reactions, especially in multiple transfusions

20. Fresh Frozen Plasma (FFP)
• FFP is plasma prepared from whole blood, either from the
primary centrifugation of whole blood into red cells and
plasma or from a secondary centrifugation of platelet rich
plasma
CONTENT
• Normal plasma levels of stable clotting factors, albumin,
immunoglobulin and Factor VIII at a level of at least 70% of
normal fresh plasma except factor V (66%), VIII (41%)
STORAGE
• Rapidly frozen to –25°C or colder within 8 hours of
collection, can be stored for upto 1yr

21. FFP cont..
IN BAG 200‐300 mL
Dosage: 2-4units (increase clotting factors by 10%)
PAEDS: 15 mL/kg
Administration:
• Should be ABO compatible
• Infuse as soon as possible after thawing
• Labile coagulation factors rapidly degrade; use
within 6 hours of thawing

22. FFP cont..
• Before use, it should be thawed in the blood
transfusion centre between +30°C and +37°C
• FFP can be thawed
Dry oven (10 minutes)
Microwave (2-3 minutes)
Water bath (20 minutes)
Thawed FFP can be used for up to 24 hours as long as it is
stored at 4ºC
Once out of the fridge, it must be used within 30 min
Once thawed should never be refrozen

23. INDICATIONS
• Dilutional effect of CPB and progressive loss of clotting factors in bleeding-can be given evn if INR is
high normal
• Patients with antithrombin III deficiency-heparin resistance
• Replacement of a single coagulation factor deficiency, where a specific or combined factor
concentrate is unavailable or contraindicated
• Immediate reversal of warfarin effect where prothrombin complex concentrate is unavailable
• In patients who are actively bleeding and whose INR is >1.5 (or POC equivalent)
• Massive blood transfusion
• Acute DIC if there are coagulation abnormalities and patient is bleeding
• Severe sepsis, particularly in neonates (independent of DIC)

24. COMPLICATIONS
• Acute allergic reactions are not uncommon,
especially with rapid infusions
• Severe life‐threatening anaphylactic reactions
occasionally occur
FFP for volume expansion can be avoided by using
crystalloid or colloid solutions

25. Cryoprecipitated anti‐haemophilic
factor (Cryo‐AHF)
• Cryo‐AHF is prepared from FFP by collecting the precipitate
formed during controlled thawing at +4°C and
re‐suspending in 10‐20 mL plasma
CONTENT
• Contains about half the Factor VIII and fibrinogen as a pack
of fresh whole blood: e.g. Factor VIII: 80‐100 iu; fibrinogen:
150‐300 mg, 40-70% von Willebrand factor, 50-1000 units
of factor XIII and 50-60mg fibronectin
STORED
• At –25°C or colder for up to 1 year

26. CRYO cont..
IN BAG
• One unit of 20 to 40 ml
• 5-6 units,100 to 200 ml
DOSE
1unit/10kg body wt
10units=fibrinogen increase by 70mg in 70kg man
PAEDS
10ml/kg

27. FORMULAE
• Blood volume=70ml/kg*wt in kg
• Plasma volume=BV *(1-Hct)
• Fibrinogen required(mg)=0.01*PV*(desired-
current)
• Bags of Cryo required=mg of fibrinogen
req/250mg

28. Administration
• ABO compatible product should be used (not
essential)
• After thawing, infuse as soon as possible
• Must be transfused within 6 hours of thawing

29. INDICATIONS
• Hypofibrinogenaemia due to major
haemorrhage and massive transfusion, vWD
• During major haemorrhage, fibrinogen should
be maintained > 1.5 g.l-1
• Combined liver and renal failure with bleeding
• Bleeding associated with thrombolytic therapy
• Disseminated intravascular coagulation with
fibrinogen < 1.0 g.l-1.

30. Leukoreduced PRBC
• Removing a proportion of the plasma from leucocyte
depleted whole blood or by leuco-depleting plasma
reduced red cells
• Non-LR RBC contain 1-3 x 109 WBC
• LR contain < 5 x 106 WBC and retains 85% of the
original cells
• HLA alloimmunization against class I antigens, febrile
reactions, and CMV infections

31. Indications
• Chronically transfused patients
• Patients with previous febrile nonhemolytic
transfusion reactions

32. Irradiated PRBC
• PRBC units are exposed to gamma irradiation
(2,500 cGy) to damage donor WBC DNA
• Prevent a cellular immune proliferative response
to the recipient’s tissues
• Cesium-137 blood irradiators
• Irradiated within 14 days of donation and it then
has a shelf life of 14 days

33. Indications
• Transplant Recipients
• Intrauterine transfusion
• Immunosuppressed patients at risk for this
complication(GVHD)
• Neonates/Infants undergoing exchange
transfusion or ECMO

34. Trigger Values
1.PRBC
Premature
Normal: <7gm/dl
Preop: <10gm/dl
Cyanotic: <12gm/dl
Term(<4m)
Normal: <7gm/dl
Preop: <10gm/dl
Ecmo: <12gm/dl
Cyanotic: <13gm/dl

35. Triggers cont..
2.PC
Premature: <30,000
Term (<4m): <20,000
Term (>4m): <10,000
Preop: <50,000
Ecmo: <100,000
3.FFP
INR: >1.5
PT> 1.5 times
4.Cryoppt
Fibrinogen: <100gm

36. Massive Blood Transfusion
• Replacement of a blood volume equivalent
within 24 hours
• >10 units within 24 hours
• Transfusion >4 units in 1 hour
• Replacement of 50% of blood volume in 3‐4
hours
• A rate of loss >150 ml/hour

37. MANAGEMENT
• Prolongation PT – FFP in a dose of 15 mL/kg
• APTT is also prolonged- Factor VIII/fibrinogen concentrate in
addition to FFP/ 10‐15 units of cryoprecipitate
• PCs only when
Clinical signs of microvascular bleeding
The patient’s platelet count falls below 50 x 109/L
Below 20 x 109/L, even if there is no clinical evidence of bleeding
The prophylactic use of platelet concentrates in patients receiving
large volume blood transfusions is not recommended.

38. AVOID
• Hypothermia
• Acidosis
• Hypocalcaemia (aim for ionised calcium > 1.0
mmol.l-1)
• Hyperkalaemia

39. AIM
• Temperature: >35 celsius
• pH: >7.2
• Base exces: <-6
• Lactate: <4mmol/lt
• Calcium: >1.1mmol/lt
• Platelets: >50,000
• PT/APTT: <1.5 times normal
• INR: <1.5
• Fibrinogen: >1gm/dl

40. Preservative solutions
CPD -21days
• Citrate is an anticoagulant,
• Phosphate serves as a buffer,
• Dextrose is a red cell energy source
CPDA -35 days
• Adenine allows RBCs to resynthesize adenosine
triphosphate (ATP), which extends the storage
time from 21 to 35 days

41. CHANGES DURING STORAGE
• RBCs metabolize glucose to lactate, hydrogen ions
accumulate, and plasma pH decreases
• 1° to 6° C stimulate the sodium potassium pump, and RBCs
lose K+ and gain Na
• The osmotic fragility of RBCs increases, and some cells
undergo lysis, resulting in increased plasma Hb levels
• Decreases in RBC concentrations of ATP and 2,3-
diphosphoglycerate (2,3- DPG)->leftward shift->decreased
offloading of oxygen

42. ADMINISTRATION OF BLOOD
PRODUCTS
When blood is transfused, it is important to keep detailed records including
the following in the patient’s notes:
Type and volume of each unit transfused
Unique donation number of each unit transfused
Blood group of each unit transfused
Time at which the transfusion of each unit commenced
Signature of the individual responsible for administration of the blood
Monitor the patient before, during and on completion of the transfusion
Record the time of completion of the transfusion
Identify and respond immediately to any adverse effect, by stopping the
transfusion
Record the details of any transfusion reaction

43. COMPATIBILITY TESTING
The laboratory performs COMPATIBILITY testing:
ABO and RhD grouping on patient and donors
Antibody screening on patient
Cross matching between serum of patient and
red cells of donor

44. CHECK POINTS
Blood bag should be checked for:
Haemolysis
Haemolysis on the line between the red cells and
plasma
Contamination, such as a change of colour in the
red cells, which often look darker/purple/ black
when contaminated
• Clot
• Leak

46. DISCARDED
The blood unit must be discarded if:
• It has been out of the refrigerator for longer
than 30 minutes
• The seal is broken
• There is any sign of haemolysis, clotting or
contamination

47. Once issued by the blood centre, the transfusion
of whole blood, red cells, platelet concentrate
and thawed fresh frozen plasma should be
commenced within 30 minutes of removal from
the optimal storage conditions

48. IDENTIFY
• The patient must be positively identified-first
name, last name, date of birth and patient
identification number
• Check that the compatibility label attached to the
blood component has the same blood group and
14-digit component donation number (or batch
number for coagulation factors or SD FFP) as the
sticker on the blood component
• Check the expiry date and time

49. Suggested rates of transfusion
Adult Rate Paediatric Rate
• Whole blood 150‐200 mL/hour 2‐5 mL/kg/hour
• PRBC 100‐150 mL/hour 2‐5 mL/kg/hour
• Platelets / plasma 150‐300 mL/hour 1‐2 mL/minute

50. Time limits for transfusion
• There is a risk of bacterial proliferation or loss of function in
blood products once they have been removed from the
correct storage conditions
• Transfusion of a unit of blood should be completed within a
maximum period of four hours after removal from the
blood fridge: discard the unit if this period is exceeded
• If blood has been out of the blood bank refrigerator for
more than 30 minutes and is not transfused, then the unit
must be returned to the laboratory, where it will be
disposed of

51. Duration times for transfusion
Start transfusion Complete transfusion
• PRBC Within 30 minutes ≤ 4 hours
• PC Immediately Within 30 minutes
• FFP As soon as possible Within 30 minutes
• Cryoprecipitate As soon as possible Within 30 minutes

52. Blood administration set
• Use a new, sterile blood administration set
containing an integral 170‐200μ filter
• Change the set at least 12‐hourly during blood
transfusion
• In a very warm climate, change the set more
frequently and usually after every four units of
blood, if given within a 12‐hour period
• Priming with saline,D5 is hypotonic, RL contains
calcium

53. Monitoring the transfusion
• Before commencing the transfusion, it is essential to encourage the
patient to notify a nurse or doctor immediately if he or she
becomes aware of any discomfort such as shivering, flushing, pain
or shortness of breath or begins to feel anxious
• Ensure that the patient is in a setting where he or she can be
directly observed
For each unit of blood transfused, monitor the patient:
- Before starting the transfusion (baseline observation).
- 15 minutes after starting the transfusion.
- At least every hour during transfusion.
- Carry out a final set of observations 15 minutes after each unit has
been transfused

54. Warming blood
• There is no evidence that warming blood is
beneficial to the patient when transfusion is slow
Warmed blood is most commonly required in:
Large volume rapid transfusions:
- Adults: more than 50 mL/kg/hour
- Children: more than 15 mL/kg/hour
Exchange transfusion in infants
Patients with clinically significant cold agglutinins

55. Use of medication at time of
transfusion
• Not recommended to routinely use
pre‐medication like anti‐histamines,
steroids,mask or delay the signs and
symptoms of an acute transfusion reaction
and therefore delay recognition and action to
stop the transfusion
• Use a separate IV line if an intravenous fluid
has to be given at the same time as blood
transfusion

56. Use of fresh blood
Stored blood less than 7 days old is termed “fresh
blood”
Uses ( to avoid biochemical overload) to raise Hb:
- Renal and liver dysfunction
- Massive blood transfusion
- Raised plasma potassium
- Neonate requiring exchange transfusion

57. TRANSFUSION REACTIONS
Acute TR (<24 hours)
- Wrong blood, primed immunological recipient
- Poor quality blood, faulty assessment
Delayed TR (>24 hours)
- Diseases, other delayed immunologic
reactions, metabolic effect (5‐10 days)

58. TRANSFUSION REACTION cont..
• With the exception of urticarial allergic and febrile
non‐haemolytic reactions, all are potentially fatal and
require urgent treatment
• The severity of the reaction and the degree of
morbidity is usually related to the volume of blood
transfused
The only sign in an unconscious or anesthetized patient
may be hypotension and uncontrolled bleeding or oozing.
In a conscious patient this may occur within minutes of
transfusion of as little as 5‐10 mL blood

59. ACUTE COMPLICATIONS

60. Haemolytic transfusion reaction
• An acute haemolytic transfusion reaction is the result
of a mismatched blood transfusion, and causes acute
intravascular haemolysis
• Antibodies in the patient’s plasma haemolyse the
incompatible red cells
• Small volume (5‐10 mL) of incompatible blood can
cause a severe reaction
• Appear within minutes

61. Bacterial contamination and septic
shock
• Affects up to 0.4% of red cells and 1‐2% of platelet concentrates
• Pseudomonas species, grow at +2°C to +6°C and can survive or multiply in
refrigerated red cell unit
• Staphylococci grow in warmer conditions and are able to proliferate in PCs
which are stored at+20°C to +24°C
• Signs usually appear rapidly after starting infusion, but may be delayed for
a few hours
• Sudden onset of high fever, rigors and hypotension
• Urgent supportive care and high‐dose intravenous antibiotics are required

62. Transfusion Associated Circulatory
Overload
• Can result in heart failure and pulmonary
edema
• May occur when:
- Too much fluid is transfused.
- The transfusion is given too rapidly.
- Renal function is impaired.

63. Anaphylactic reaction
• Rare, risk is increased by rapid infusion, typically when fresh frozen plasma
is used
• IgA deficiency in the recipient is a rare cause of very severe anaphylaxis
• This can be caused by any blood product since most contain traces of IgA
Occurs within minutes of starting the transfusion and is characterized by:
- Cardiovascular collapse.
- Respiratory distress.
- No fever
Anaphylaxis is likely to be fatal if it is not managed rapidly and aggressively.

64. Transfusion Related Acute Lung Injury
• Caused by donor plasma that contains antibodies
against the patient’s leucocytes
• Rapid failure of pulmonary function usually presents
within 1‐4 hours of starting transfusion, with diffuse
opacity on the chest X‐ray
• No specific therapy
• Intensive respiratory and general support in an
intensive care unit is required

65. DELAYED COMPLICATIONS

66. Delayed haemolytic transfusion
reaction
Signs appear 5‐10 days after transfusion:
Fever.
Anaemia.
Jaundice.
Occasionally haemoglobinuria.
Severe, life‐threatening delayed haemolytic
transfusion reactions with shock, renal failure and
DIC are rare

67. Post‐transfusion purpura
• This is a rare but potentially fatal complication of
transfusion of red cells or platelet concentrates, caused
by antibodies directed against platelet‐specific antigens
in the recipient
• Multigravida female patients
Signs and symptoms:
– Signs of bleeding.
– Acute, severe thrombocytopenia 5‐10 days after
transfusion, defined as a platelet count of <100 x 109/L.

68. MANAGEMENT
Management becomes clinically important at a platelet count
of 50 x 109/L, with a danger of hidden (occult) bleeding at 20
x 109/L.
• High dose corticosteroids
• High dose IV immunoglobulin, 2 g/kg or 0.4 g/kg for 5 days
• Plasma exchange
• Monitor the patient’s platelet count
• Platelet concentrates that are negative for the
platelet‐specific antigen against which the antibodies are
directed
• Recovery of platelet count after 2‐4 weeks is usual

69. Transfusion associated
graft‐versus‐host disease (TA‐GVHD)
• Fatal condition
Occurs in patients such as:
– Immuno‐deficient recipients of bone marrow transplants
– Immuno‐competent patients transfused with blood from individuals with
whom they have a compatible HLA tissue type, usually blood relatives
particularly 1st degree
Signs and symptoms typically occur 10‐12 days after transfusion and are
characterized by:
– Fever
– Skin rash and desquamation
– Diarrhoea
– Hepatitis
– Pancytopenia

70. TA-GVHD cont..
Management
• Treatment is supportive; there is no specific
therapy.
Prevention
• Do not use 1st degree relatives as donors, unless
gamma irradiation of cellular blood components
is carried out to prevent the proliferation of
transfused lymphocytes

71. Delayed complications: transfusion
transmitted infections
• HIV, Hepatitis B and C, syphilis (Treponema
pallidum), malaria
Cytomegalovirus (CMV)
Other TTIs include human parvovirus B19,
brucellosis, Epstein‐Barr virus, toxoplasmosis,
Chagas disease, infectious mononucleosis and
Lyme’s disease.

72. Duration of red-cell storage and complications after cardiac surgery.
N England J Med 2008 Mar 20;358(12):1229-39. Koch CG, et al.
In patients undergoing cardiac surgery,
transfusion of red cells that had been stored for
more than 2 weeks was associated with a
significantly increased risk of postoperative
complications as well as reduced short-term and
long-term survival.

73. Increased mortality, postoperative morbidity, and cost after red blood cell
transfusion in patients having cardiac surgery.
Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA,
Red blood cell transfusion in patients having
cardiac surgery is strongly associated with both
infection and ischemic postoperative morbidity,
hospital stay, increased early and late mortality,
and hospital costs.

74. THANK YOU