Critical care management with special emphasis on OB and Gynecology cases.

1. BY
DR.MUHAMMAD AKRAM KHAN QAIM KHANI
MATERNITY AND CHILDREN HOSPITAL
MAUSADIA, JEDDAH
Together, we can save a life. It is one of the most important things you can do.

3. Transfusion of blood remained mysteriously unsafe
until the discovery of blood groups by K. Land
Steiner in 1900
Cell separators introduced in 1970s
HBsAg screening introduced in 1968
THE COMPONENT SYSTEM
Most patient needing transfusion do not require all
of the component available
Component therapy “STRETCHES” the blood supply
by allowing prolonged storage of stable factors and
permitting several patients to receive the specific
component they need from a single donor
Reduced risk of fluid overload and infection

4. BLOOD COMPONENT
RED CELL CONCENTRATE ( PRBCs )
LEUCOCYTE POOR RED CELL CONCENTRATE
PLATELET RICH PLASMA ( PRP )
GRANULOCYTE CONCENTRATE
FRESH FROZEN PLASMA ( FFP )
CRYOPRECIPITATE
SINGLE DONOR PLASMA
CRYO POOR PLASMA
PLASMA DERIVATIVES
ALBUMIN
PLASMA PROTEIN FRACTION ( PPF )
FACTOR VIII CONCENTRATE
FIBRINOGEN
IMMUNOGLOBULINS
OTHER COAGULATION FACTORS

5. Donor blood mixed with anticoagulant preservative
Indicated in emergent restoration of circulating volume and O2 – carrying
capacity in massively bleeding patient
Nowadays its use is based on EMOTIONAL rather than rational argument
May produce circulatory overload if transfused to a euvolemic patient
FRESH WHOLE BLOOD
Less than 06-08 hours old
Platelets become nonfunctional within 24 hours after collection
After 48 hours, essentially all factor VIII is depleted
Within 01 week, even the longer lived factor V is depleted
30% RBCs may be lost after 03 weeks of storage
Fresh blood is used to prevent dilutional coagulopathy in massively
transfused patients who require 10 or more units of whole blood within 24
hours period
A unit of whole blood ( approximately 350 ml) will increase Hemoglobin by
about 0.75gm/dl

6. Removing plasma from whole blood leaves a 200-300 ml of PRBCs, having a
PCV of 65-75%
Used to restore oxygen carrying capacity of blood
One unit transfused should raise the PCV of an adult patient by 03%
Red blood cells may be stored under refrigeration for a maximum of 42 days,
or they may be frozen for up to 10 years.
Can be infused rapidly by adding 75ml of normal saline
Anemia is the primary indication for transfusion of RBCs.
Normal hemoglobin levels are between 12 g/dL and 16 g/dL for women, and
14 g/dL and 18 g/dL for men
The hematocrit—the proportion of RBCs in the total volume of blood—can
also determine if a patient is anemic. A normal hematocrit value ranges from
37 to 48 for women, and 45 to 52 for men
Typically, transfusions are administered at the “10/30 trigger” (hemoglobin,
10 g/dL; hematocrit, 30)
Losing large amounts of blood suddenly can cause
Drop in blood pressure and subsequently
increase in cardiac output

7. The rationale for blood transfusion is rooted in the physiology of
oxygen delivery
Oxygen delivery (DO2) = (Hb level x %sat x
1.34) + (PaO2 x 0.003) x C.I.
Hb level is in g/dl, 1.34 is the amount of oxygen in mls carried by
one gram of Hb (the Hufner constant), PaO2 is the partial pressure
of oxygen dissolved in the blood measured in mmHg and C.I. is the
cardiac output standardized to body surface area) better oxygen
delivery ought to be the result
A reduction in oxygen delivery below a critical level deprives tissues
of the oxygen necessary for oxidative metabolism and results in a
shift to anaerobic metabolism.
The minimum tolerated hemoglobin level is not well established,
Conventional transfusion triggers of 10 g/dl have been challenged
by reports indicating that aerobic metabolism is supported by
hemoglobin levels of 5.0 g/dl or less.

8. No justification for transfusion of RBCs required
if.
Acutely bleeding patients as might be indicated
by: Rapid (within four hours) blood loss of > 15% of
total blood volume regardless of the measured blood
hemoglobin or hematocrit value. This would correspond
to a recorded volume lost, or need to replace with
intravenous fluids, of 10 ml per kg patient body weight
(e.g. 700 ml blood loss with 4 hrs in a 70 kg patient).

9. A multi center, randomized, controlled trial, was conducted between
1994 and 1997.
In this study euvolemic patients in the intensive care unit were
randomized to either a restrictive or to a liberal transfusion policy.
In the restrictive group, patients were transfused when the
hemoglobin level was less than 7.0 g/dl, with a target hemoglobin
level of 7.0 to 9.0 g/dl.
In the liberal group, transfusions were given when the hemoglobin
level was less than 10.0 g/dl, with a target range of 10.0 to 12.0 g/dl.
There were a number of exclusion criteria including patients with
ongoing bleeding or chronic anemia and patients undergoing cardiac
surgery.
when outcome data were analyzed, patients in the restrictive arm
exhibited a strong trend toward improved 30-day survival and a
significant improvement in hospital survival.
The development of new organ dysfunction in the ICU was
significantly less in patients randomly assigned to the restrictive arm
The best evidence currently available suggests that transfusion can
safely be withheld as long as the hemoglobin remains above 70 g/l
and the patient is not actively bleeding

10.  A multicenter randomized, controlled clinical
trial of transfusion requirements in critical
care
 Designed to compare a restrictive vs. a liberal
strategy for blood transfusions in critically ill
patients

11.  838 patients with euvolemia after initial
treatment who had hemoglobin
concentrations < 9.0g/dl within 72 hours of
admission were enrolled
 418 pts: Restrictive arm: transfused for
hb<7.0
 420 pts: Liberal arm: transfused for Hb< 10.0

12.  Age <16
 Inability to receive blood products
 Active blood loss at time of enrollment
 Chronic anemia: hb< 9.0 in preceding month
 Routine cardiac surgery patients

13. 4.3%1.4%Noncompliance
>48hrs
5.6+ 5.32.6+ 4.1# of transfusions
10.7+0.78.5+0.7Average Hemoglobin
Liberal
Group
Restrictive Group

14. Restrictive
group
Liberal group
Rate of death at 30
days
18.7% 23.3
Mortality rates 22.2% 28.1

15. restrictive liberal
cardiac 13.2% 21.0%
MI 0.7% 2.9%
Pulm edema 5.3% 10.7%
ARDS 7.7% 11.4%
Septic shock 9.8% 6.9%

17. Risks of red blood cell transfusion (adapted from British Committee for
Standards in Haematology (2001)1)
Risk factor
Estimated frequency per
unit transfused
Death per
million units
Acute haemolytic reactions 1 in 250 000 to 1 in
1 000 000
0.67
Hepatitis B 1 in 100 000 to 1 in
400 000*
<0.5
Hepatitis C 1 in 3 000 000 <0.5
HIV 1 in 4 000 000 <0.5
Bacterial contamination of red cell
concentrates
1 in 500 000 <0.25
* Data from Kate Soldan, National Blood Service and Central Public Health
Laboratory.
Data from Dr Pat Hewitt and Dr John Barbara, National Blood Service, North
London.

18.  Leukocyte-reduced= 108 WBCs prevent
FNHTR
 Leukocyte-depleted= 106 WBCs prevent
alloimmunization and CMV transmission
 Washed: plasma proteins removed to prevent
allergic reaction
 Irradiated: lymphocytes unable to divide,
prevents GVHD

19. A unit of donor whole blood contains 2 billion white cells per ~450
ml unit
Even with blood component processing, 90% of these cells remain
with RBCs
Leukocyte poor RBCs implies the removal of at least 70% of
leukocyte, with a loss of ~10% of the red cells.
CMV , HTLV-1, and HTLV-II ( Human T cell Leukemia Virus ) are only
transmitted by transfusion of cellular component. And if universal
leukoreduction is adopted then it would be no longer be necessary
to test for these viruses
Leukoreduction may occur in two forms : PRESTORAGE and
POSTSTORAGE filtration. In USA and Canada pre storage leuko
reduction is done
Pre storage leukoreduction not only decreases the incidence of
certain virus transmission but also eliminates the delay associated
with filtering blood in a patient requiring urgent transfusion
Through the use of CENTRIFUGATION OR FILTRATION, 99.995%
leukocyte reduction can be accomplished

20. WASHED RBCs
Saline washing of RBCs results in the removal of majority of
platelets and leukocytes
Indicated in patients who are sensitive to plasma proteins
or when multiple transfusions are anticipated
FREEZING AND DEGLYCEROLIZATION
Leukocyte poor RBCs prepared by freezing and
deglycerolization has lower levels of leukocytes than any
other methods but it is costly and time consuming
This technique is used for rare units of RBCs
ADVANTAGES OF LEUKODEPLETED PRODUCTS
Reduced risks of
Febrile Non Hemolytic Reaction ( FNHTR)
Sensitization to blood products
Disease transmission like CMV

21. Blood removed from a critically ill patient for testing can
average more than 70 ml/day for days or even weeks,
depending on the nature and the severity of the illness
The presence of an arterial catheter may increase blood
testing by as much as one third
Waste of blood occurs each time a catheter is aspirated
and flushed , and the risk for nosocomial infection is
increased both by catheter manipulation and by
transfusion of allogeneic packed red blood cell
concentrates
NONINVASIVE HEMODYNAMIC MONITORING
Pulmonary artery catheterization is employed less frequently
now as compared with as recently as 5 years ago, owing to
increasing reliance on echocardiography and esophageal
Doppler estimates of aortic blood flow, and to evidence that
use of pulmonary artery catheters may be associated with
increased mortality

22. Noninvasive measurement of arterial blood pressure is
accurate and the technology is widely available.
Capnometry and Pulse Oxymetry in ICUs to minimize frequent
extraction of blood for ABGs
The yield of 'fever work-ups' in general, and blood cultures in
particular, is very low in the early postoperative period (< 72
hours), and therefore evaluation is usually not indicated.
POINT-OF-CARE TESTING ( POC)
Testing of blood samples at or near the bedside
Very small (i.e. microliter) blood samples are required, and in
some cases are not even removed from the patient because
indwelling sensors or a closed circuit extracorporeal sampling
device is employed to permit return of the sample to the
patient after analysis.
Most prevalent example of POC testing is glucose monitoring

23. Limited blood use policy
Erythropoetin
Artificial hemoglobin
Biopure (An HBOC developed by Biopure
Corporation, made from bovine blood )
HBOC (A hemoglobin oxygen carrier)
DCLHBG (Diaspirin cross-linked hemoglobin)

24. DEFINITION
Plasma separated from whole blood, frozen within 06 hours of collection and stored
at -30°C and bellow
FFP contains fibrinogen; clotting factors II, V, VII, IX, X, XI, XIII; and Von
Willebrand factor
A unit contains 180-300ml of Plasma
INDICATION
PT OR PTT >1.5
Multiple coagulation factor deficiencies 2ndry to Liver disease, DIC, TTP, and
Dilutional coagulopathy due to massive blood transfusion
Reversal of Coumarin ( Warfain and Dicumoral ) effect
Antithrombin deficieny which may occur due to OCPs, or patients with Liver dissorder
DOSAGE
10-15ml/kg
May have to exceed in massively bleeding patient
The dose advised for reversal of Warfarin is half the dose
LAB MONITORING
To keep PT/PTT <1.5X normal

25. INDICATION
Platelet count <5,000
Amegalokaryocytic thrombocytopenia
Leulkemia
Hypoplastic Anemia
Dilutional thrombocytopenia e.g. massive blood transfusion with
stored blood
DIC
Functional Platelet abnormalities
Prophylactic Platelet transfusion are rarely indicated with Platelet
count >10K
Indicated in bleeding patient when Platelet count is <50,000.
If count is between 50 – 100,000, the need for transfusion should
be based on the risk of bleeding
Vaginal deliveries and operations are associated wit insignificant
blood loss, may be undertaken if the PLT <50,000

26.  Clinical situation: Fever, sepsis,
splenomegaly, Bleeding, DIC
 Patient: alloimunization, underlying disease,
drugs (IVIG, Ampho B)
 Length of time platelets stored
 15% of patients who require multiple
transfusions become refractory
 Joel Saltzman MD Hematology/Oncology FellowMetro Health Medical Center

27.  Treat underlying condition
 Transfuse ABO identical platelets
 Transfuse platelets <48 hrs in storage
 Increase platelet dose
 Select compatible donor
◦ Cross match
◦ HLA match
 Joel Saltzman MD Hematology/Oncology FellowMetro Health Medical Center

28.  Febrile nonhemolytic transfusion: caused by
patients leucocytes reacting against donor
leukocytes
 Allergic reactions
 Bacterial contamination: most common blood
product with bacterial contamination
 Joel Saltzman MD Hematology/Oncology FellowMetro Health Medical Center

29. DOSE AND ADMINISTRATION
Infuse over not more than 30 mins.
One unit of PLT usually increases platelet count by 5K –
100K in a 70kg.adult
The dose of PLT transfusion should increase the PLT
count by 50K, therefore one PLT unit / 10kg.
The efficacy of PLT transfusion can be assessed by doing
PLT count at one hour. And 4-6/24 Hr. post transfusion
an increment of <2K, per unit confirms platelet
destruction
Following formula can help to calculate the Corrected
Count Increment( CCI) for PLT transfusion
CCI = Post transfusion PLT – pre transfusion PLT X BSA M²
No. of PLT Unit transfused

30. EXAMPLE
If a pt. having a body surface area of 2M² is transfused
with 04 unit of PLT with initial count of 15000 and post
transfusion count of 55,000
CCI = 55000 – 15000 x 2 = 20K
2

32. DEFINITION
It is the insoluble portion of Plasma left after the
FFP has been thawed under controlled conditions
The precipitate contains most of the factor VIII (
about 80 – 100unit ), Fibrinogen ( 250 mg ), and 40
– 60% of the Von Willebrand’s factor present in the
original unit Plasma.
INDICATION
Hypofibrinogenemic states ( e.g. thrombolytic therapy,
Congenital deficiency, and consumptive coagulopathy )
Hemophilia A ( factor VIII deficiency )
Von Willebrand's disease

33. DOSE AND ADMINISTRATION
In Hypofibrinogenemic state,
one bag of Cryoprecipitate/5 kg.of body weight is
a usual dose
When used for Von Willebrand’s disease, one bag
/ 10kg is usually adequet
Nowadays,factor VIII concentrate are favored over
Cryoprecipitae for treatment of Von Willebrand’s
Disease

34. Preapered from the plasma of many ( frequently hundreds )
donors, is used for the treatment of Hemophilia A
For the bleeding hemophilac, factor VIII activity is negligible
and should be increased to >50% of normal levels to arrest
hemorrhage
CALCULATION FOR FACTOR DOSES
The doses may be calculated by replacing 01 unit of factor VIII per
milliliter of calculated plasma volume per cent of desired factor
VIII
Blood volume ( ml) = wt. in kg. X 70
Plasma volume ( ml) = blood volume X ( 1 – PCV fraction )
Units of factor VIII = plasma volume X ( desired factor VIII% - current
factor VIII% )
◦ Alternatively, the rough calculation may be
 DOSE ( units ) = 40 X ( wt. in kg. ) X ( % factor VIII activity desired )

35. Because factor VIII has a half life of only 08 – 12
hours, close monitoring of clinical signs of
bleeding and factor VIII level is necessary

37.  Increased pulse Hypertension
 Hypotension Congestive Heart Failure
 Cyanosis Chills
 Dyspnea Fever (a 2°rise is considered a
 Chest pain febrile reaction)
 Nausea Hemoglobinuria
 Vomiting Rash
 Back pain Heat or pain along the
 Flushing vein of transfusion
 Urticaria
 Other symptoms that would cause concern to the
nurse or patient

38.  Hemolytic transfusion reaction
◦ The destruction of transfused red cells. The most common cause
of acute hemolytic reactions is transfusion of ABO incompatible
blood, resulting from identification errors occurring at some
point(s) in the transfusion process. Type and cross matches are
done to try to prevent this type of reactions.
 Acute hemolytic reaction
◦ Characteristically begin with an increase in temperature and pulse
rate; symptoms may include chills, dyspnea, chest or back pain,
abnormal bleeding or shock. Instability of blood pressure is
frequent, the direction and magnitude of change depending upon
the phase of the antigen-antibody event and the magnitude of
compensatory mechanisms

39.  Delayed Hemolytic reactions:
Occur in previous alloimmunized patients in whom antigens
on transfused red cells provokes anamnestic production of
antibodies that reaches a significant circulating level while the
transfused cells are still present in the circulation;
the usual time frame is 2 to 14 days after transfusion.
Signs may include unexplained fever, development of a
positive direct antiglobulin test, an unexplained fall in
hemoglobin/hematocrit. Hemaglobinemia and
hemoglobinuria are uncommon, but elevation of LDH or
bilirubin may be noted. Most delayed hemolytic reactions
have a benign course and require no treatment.

40. Febrile non-hemolytic reaction
Typically manifested by a temperature elevation of >1°C or 2°F
occurring during or shortly after a transfusion and in the absence of
any other pyrexic stimulus.
This may reflect the action of antibodies against white blood cells
or the action of cytokines, either present in the transfused
component or generated by the recipient in response to transfused
elements.
Febrile reactions may accompany about 1% of transfusions; they
occur more frequently in patients alloimmunized by transfusion or
pregnancy and in patients immune dysfunction due to neoplasm or
autoimmunity.
Patients who experience repeated, severe febrile reactions may
benefit from receiving luekocyte reduced components.
Allergic Reactions
Usually occurs as urticaria, but may also include wheezing or
angioedematous reactions.

41. • Transfusing 1 blood volume replacement (10-20
units for most adults) in less than a 24 hour period
or as an acute administration of more than ½ the
patient’s EBV per hour
• Main objective is to improve and maintain adequate
oxygen carrying capabilities, hemostasis, oncotic
pressure, and biochemistry
• Multiple studies show 18-30% of massively
transfused patients develop a coagulopathy
• There is debate whether or not to prophylactically
replace platelets and coagulation factors or wait
until there is abnormal micro vascular bleeding and
laboratory evidence of coagulation factor
deficiencies

42. • Metabolic acidosis is uncommon unless there is inadequate
resuscitation
• Blood pH is 6.9 after 21 days of storage, due to continued
RBC metabolism of glucose to lactate and pyruvate and bags
are impermeable to CO2. pH 6.9 after 21 days and 6.71 after
35 days
• Metabolic alkalosis (MA) is the most common pH abnormality
after massive blood transfusions
• Progressive MA results as citrate & lactate in the transfusion
convert to bicarbonate in the liver
• MA most likely to occur in patients with renal dysfunction
since kidneys are responsible for HC03 elimination.
• If alkalosis occurs, there is a left shift for O2 affinity, and a
possibility for cellular hypoxia. There is also a decrease in 2,3
DPG for a left shift of O2
• Compensation for these abnormalities by increasing CO2 and
increase O2 delivery

43.  So how much time
has passed since
we started?
 Many, many people
have needed blood.
 Remember, the only
way for someone to
receive blood is for
another person to
donate it.