1) Blood transfusion therapy was established in the late 19th century and involves typing and cross-matching donor and recipient blood to minimize complications. 2) Common indications for transfusion include improving oxygen carrying capacity, treating anemia, and volume replacement after blood loss. 3) Potential complications include non-hemolytic fever reactions, circulatory overload, transfusion-related lung injury, hemolysis, and disease transmission, though screening has reduced the latter. Careful patient selection and monitoring can help prevent complications.

1. BLOODTRANSFUSION & IT’S
COMPLICATION
Dr. Priyadarshan Konar
1st year PGT
Department of General Surgery
IMS & SUM Hospital
Bhubaneswar
31.03.2017

2. INTRODUCTION
 Human blood replacement therapy was accepted in the
late 19th Century.
 This was followed by the introduction of blood grouping
by Landsteiner who identified the major blood groups
A, B and O in 1900.
 Levine and Stetson introduced the concept of Rh Typing
in 1939.
 Whole blood was considered the standard in transfusion
until the late 70’s when component therapy began to
take prominence.

4. REPLACEMENT THERAPY
TYPING AND CROSS-MATCHING:
Serologic compatibility for A, B, O, and Rh groups is
established routinely.
Cross matching between donor’s RBC and recipient’s sera is
performed.
Rh negative blood which accounts for 15% of the population,
should only be transfused to Rh negative blood group only.

5. In emergency situations, type O-negative blood may be
transfused to all recipients.
Problems are associated with the administration of four or
more units, because there is a significant increase in risk of
hemolysis.
Nowadays, the use of autologus transfusion is growing.
Upto 5 units can be collected for subsequent use during
elective procedures. (If Hb exceeds 11gm/dL or hematocrit
>34%)

6. BANKED WHOLE BLOOD:
Once the gold standard, rarely available in western
countries now.
With sequential changes in storage solutions, the shelf life
of RBC’s is now 42 days.
During storage of RBC’s reduction of intracellular ADP and
2,3 DPG occurs, which alters oxygen dissociation curve of
Hb, resulting in decrease oxygen transport.
Stored RBC’s progressively becomes acidodic with elevated
levels of lactate, potassium & ammonia.

7. RBC’s & FROZEN RBC’s:
They are the product of choice for most clinical situations.
It can be prepared by removing most of the supernatant
plasma after centrifugation.
This preparation reduces but does not eliminate reactions
caused by plasma components.
Whereas, in frozen RBC’s viability is improved and ATP &
2,3 DPG concentrations are maintained.
Frozen RBC’s are not available for use in emergencies.

8. LEUCOCYTE-REDUCED AND LEUKOCYTE-
REDUCED/WASHED RED BLOOD CELLS:
These products are prepared by filtration that removes
about 99.9% of the WBC’s and most of the platelets and if
necessary, by additional saline washing.
This leucocyte reduction prevents nonhemolytic transfusion
reaction (fever and/or rigors), alloimmunization to HLA class
I antigens, platelet transfusion refractoriness & CMV
transmission.
In most western nations it is standard RBC transfusion.

9. PLATELET CONCENTRATES:
Indications for platelet transfusion include thrombocytopenia
caused by massive blood loss, inadequate platelet production
or qualitative platelet disorders.
Shelf life is 120 days.
1 unit of platelet concentrate has a volume of approx. 50ml.
Recent evidences suggests that earlier use of platelets may
improve outcomes in bleeding patients.
Patients who become alloimmunized through previous
transmission , HLA-matched platelets can be used.

10. FRESH FROZEN PLASMA:
Prepared from freshly donated blood.
Usual source of vitamin K-dependent factors & the only
source of factor V.
Carries similar infectious risk as other component therapies.
FFP can be thawed and stored for up to 5 days.
Nowadays, lyophilized plasma is being tested – to increased
the shelf life and avoid refrigeration.

11. CONCENTRATES AND RECOMBINANT DNA
TECHNOLOGY:
 Technologic advancements have made the majority of
clotting factors and albumin readily available as
concentrates.
 These products are readily available and carry none of the
inherent infectious risks as other component therapies.

12. INDICATIONS
1. IMPROVEMENT IN OXYGEN CARRYING CAPACITY
2. TREATMENT OF ANAEMIA
3. VOLUME REPLACEMENT
4. NEW CONCEPTS IN RESUSCITATION – DCR

13. 1. IMPROVEMENT IN OXYGEN CARRYING CAPACITY:
Oxygen carrying capacity is primarily a function of the RBC’s &
thus transfusion of RBC’s should augment oxygen carrying
capacity.
Hb is fundamental to arterial oxygen content and it’s delivery.
There is little evidence that actually supports the premise that
transfusion of RBC’s equates with enhanced cellular delivery &
utilization.
This happens due to changes that occurs with storage of blood
- in 2,3-DPG & P50 impair oxygen offloading, and
deformation of RBC’s impairs microcirculatory perfusion.

14. 2. TREATMENT OF ANAEMIA:
A 1988 NIHC Report challenged the dictum that a Hb value of
less than 10gm/dL or Hct level less than 30% indicates a need
for preoperative RBC transfusion.
This was verified in a prospective RCT in critically ill patients
and demonstrated that maintaining Hb level between 7 & 9
gm/dL had no adverse effect on mortality.
One unresolved issue related to transfusion triggers is the
safety of maintaining a Hb of 7 gm/dL in a patient with
Ischaemic Heart Disease.

15. “The recommendation assigns two tiers of hemoglobin level
transfusion triggers:
 7 g/dL for hemodynamically stable adults, even those in
critical care
&
 8 g/dL for patients with preexisting cardiovascular disease
or those undergoing cardiac or orthopedic surgery. The
current hemoglobin threshold was 10 g/dL”.
RECENT RECOMMENDATION IN BLOOD TRANSFUSION:
(Published in JAMA, October 2016 by AABB)

16. 3. VOLUME REPLACEMENT:
The most common indication for blood transfusion in surgical
patients.
Deficit is difficult to evaluate.
Measurement of Hb & Hct can be misleading in the face of acute
loss.
Amount & rate of bleeding are more important factors.
Loss of blood in OR can be roughly evaluated by amount of blood
in the wound and drapes, weighing the sponges & quantifying
the blood suctioned from the operating field.
Loss of 20% of total blood volume can be replaced with
crystalloid / colloid solutions. More than this may require
addition of balanced resuscitation, eg. PRBC, FFP & Platelets.

17. Volume in the suction bottle x Suction PCV
 Blood loss =
Patient PCV
 In acute haemorrhage, the immediate Hct may may not
actually reflect the blood loss.
 Total amount of blood loss=
• Total difference in swab weight x 1.5, or
• Total difference in swab weight x 2 (for larger operations)
Source: Canadian Journal Of Anesthesia
Estimation of blood loss in Operating Room:

18.  Maximum capacity of swab:
1. Small (10 x10cm)  60ml
2. Medium (30 x 30cm)  140ml
3. Large(45 x 45cm)  350ml
 Floor spill:
1. 50cm diameter  500ml
2. 75cm diameter  1000ml
3. 100cm diameter  1500ml

19. 4. NEW CONCEPTS IN RESUSCITATION – DCR:
Damage Control Resuscitation (DCR) strategy, aimed at halting
and/or preventing rather than treating the lethal triad of
Coagulopathy, Acidosis, and Hypothermia, has challenged
traditional thinking on early resuscitation strategies.
Standard advanced trauma life support guidelines start
resuscitation with crystalloid, followed by PRBC.
Because of the known early coagulopathy of trauma, the
current approach to managing the exsanguinating patient
involves early implementation of DCR.

20.  DCR is actually composed of 3 basic components:
1. Permissive hypotension
2. Minimizing crystalloid based resuscitation
3. Administration of predefined blood products
(RBC’s, plasma and platelet) in ratios similar to
those of whole blood.
 During recent time, in Iraq & Afghanistan, DCR
practices are demonstrating unprecedented success
with improved overall survival.

21.  A multicenter retrospective study of modern transfusion
practice showed that Plasma:Platelet:RBC ratios varied from
1:1:1 to 0.3:0.1:1, with corresponding survival rates ranging
from 71% to 41%.
 Similarly, in a prospective observational study evaluating
current transfusion practice documented the wide variability in
practice and improved outcomes with earlier use of increased
ratios of plasma and platelets. Patients receiving ratios less than
1:2 were four times more likely to die than patients with ratios
of 1:1 or higher.

22. Several authors have shown that a well developed massive
transfusion protocol is associated with improved outcomes
independent of the ratios chosen – And this should begin
prior to any laboratory defined anemia or coagulopathy.
Adult Massive Transfusion Guidelines (MTG) specify the early
use of component therapy.

24. Specific recommendations for the administration of
component therapy during a massive transfusion:

25. COMPLICATIONS
Primarily related to blood induced proinflammatory responses.
Occur in approximately 10% of all transfusions, but less than
0.5% are serious in nature.
Death occur rarely and are primarily related to TRALI (16%-
22%), ABO hemolytic transfusion reactions(12%-15%), and
bacterial contamination of platelets (11%-18%).

26. A. NON HEMOLYTIC TRANSFUSION REACTION (NHTR)
B. TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD
(TACO)
C. TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)
D. HEMOLYTIC REACTION
E. TRANSMISSION OF DISEASES

27. A. NON HEMOLYTIC TRANSFUSION REACTION (NHTR)
Increase in temperature (>1°c) associated with
transfusion and are fairly common.
Occurs 0.5-1.5% of all transfusions.
Etiology - Preformed cytokines in donated blood and
recipient Ab reacting with donated Ab
Prevention – Leukocyte reduced blood products, store
platelets <5days. Pretreatment with acetaminophen
reduces the severity of the reaction.

28.  Bacterial contamination of infused blood is rare.
 High fever, chills, Hemodynamic changes, DIC, Emesis,
Diarrhoea, Hemoglobinuria.
 Bacterial contamination can result in sepsis & death in
up 25% of patients.
 <<0.05% of blood & 0.05% of platelets.
 Etiology – Gram negative Bacteria
 Emergency treatment includes Oxygen, Adrenergic
blocking agents, and antibiotics

29.  Allergic reactions are relatively frequent, occurs in about 1%
of all transfusions.
 Rash, Urticaria & Flushing. (Rarely Anaphylactic shock)
 Caused by transfusion of antibodies from hypersensitive
donors or transfusion of antigens to which the the recipient
is hypersensitive.
 Commonly associated with FFP and Platelets.
 Administration of antihistamine prophylaxis.

30. B. TRANSFUSION ASSOCIATED CIRCULATORY
OVERLOAD (TACO)
Respiratory compromise due to pulmonary edema.
Occur with rapid infusion of blood, plasma expanders, and
crystalloids, particularly in older patients with underlying
heart disease.
Can be avoided by slowing the rate of blood transfusion,
administration of diuretics and minimizing fluids

31. C.TRANSFUSION RELATED ACUTE LUNG INJURY
(TRALI)
Defined as noncardiogenic pulmonary edema related to
transfusion.
Symptoms are Acute Hypoxemia, Bilateral pulmonary
infiltrates, Tachycardia, Hypotension.
Occurs 1-2hrs of transfusion, but virtually always before 6hrs.
Etiology – Anti-HLA or Anti-HNA antibodies in transfused
blood attacks circulatory and pulmonary leukocytes.
In a recent study by TOY et al reported decrease in incidence
of TRALI with the reduction transfusion of plasma from
female donors.

32. D.HEMOLYTIC REACTION
This can be classified as either Acute or Delayed.
Occur due to administration of ABO incompatible blood.
Contributing factors are errors in the laboratory of a technical
or clerical nature or the administration of wrong blood type.
Causes immediate hemolytic reactions are characterized by
intravascular destruction of RBC’s & consequent
hemoglobinemia and hemoglobinuria – and finally ARF.
Most common symptoms are pain at the site of transfusion,
facial flushing and back & chest pain.

33. Delayed hemolytic reaction occur 2-10 days after
transfusion.
Characterized by extravascular hemolysis, mild anemia and
indirect (unconjugated) hyperbilirubinemia.
Etiology – Reactions to non-ABO antigens involve
immunoglobulinG mediated clearance by the
reticuloendothelial system.

34. E. TRANSMISSION OF DISEASES
Malaria, Chagas disease, Brucellosis, and very rarely Syphillis
are among the diseases that have been transmitted by
transfusion.
The most common species is Plasmodium Malariae.
Initial manifestations are Shaking chills and spiking fevers.
Transmission of Hep C and HIV-1 has been dramatically
minimized by the introduction of better antibody and
Nucleic acid screening for these pathogens.