|Year : 2014 | Volume
| Issue : 3 | Page : 220-226
Blood component therapy in anesthesia and intensive care: Adoption of evidence based approaches
Sukhminder Jit Singh Bajwa1, Ashish Kulshrestha2
1 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India
2 Department of Anaesthesiology and Intensive Care, Government Medical College and Hospital, Sector-32, Chandigarh, India
|Date of Web Publication||19-Sep-2014|
Sukhminder Jit Singh Bajwa
House No. 27-A, Ratan Nagar, Tripuri, Patiala, Punjab
Source of Support: None, Conflict of Interest: None
Transfusion of blood and its components has undergone technological advancement, and its use is increasing both perioperatively as well as in the Intensive Care Unit. The separation of blood into its various components has made it very economical as blood donated from a single donor can be utilized for many recipients at the same time. However, the transfusion of blood and its components do carry the inherent risk of various transfusion reactions as well as transmission of infections. The indications for transfusion should be strictly adhered to for preventing nonjudicious use. The health care persons involved in transfusion should be well aware of implications of the mismatched transfusion and should be able to provide treatment if such mishaps do occur. A health care professional should carefully weigh the benefits of blood transfusion against the risks involved before subjecting the patients to the transfusion. This manuscript aims to comprehensively review the current evidence based approaches in blood and component transfusion which are being followed in anesthesiology and intensive care practice.
Keywords: Blood transfusion, guidelines, indications, transfusion reactions
|How to cite this article:|
Bajwa SS, Kulshrestha A. Blood component therapy in anesthesia and intensive care: Adoption of evidence based approaches. J Sci Soc 2014;41:220-6
| Introduction|| |
With the technological advances in transfusion medicine involving separation of blood components, transfusion of blood components has increased tremendously especially in critically ill patients in Intensive Care Units (ICUs). In modern day clinical practice, the clinicians can choose from a range of blood products depending on the requirement of specific patients. Admission pattern in ICU is highly variable with patients getting referred from all specialties which may include wide demographic variation in admission pattern ranging from neonates to geriatric age group, from surgical to medical specialties; hence it is emphasized that the intensivist be aware of different pathologies and their different requirements in the context to blood and its components therapy [Figure 1].
|Figure 1: The process of separation of whole blood into its various components|
Click here to view
According to the report of Serious Hazards of Transfusion in UK in 2009, it was found that total number of blood components issued was close to 3 million. The blood requirement in Southeast Asian region is about 15 million units annually. The major indications for transfusion being: Trauma, shock, septicemia, emergency obstetric care, vascular surgery, hemodialysis, pediatric and hematological emergencies.
The new evidence based recommendations dictate that blood should be transfused only when required to save a life and not just to treat lab values.
| Blood and its components|| |
The whole blood constitutes about 8% of human body weight. Primarily, the indications for blood transfusion based on evidence based recommendations can be summed as. 
Indications for whole blood transfusions (evidence based recommendations)
- Patients developing hypovolemia due to massive blood loss.
- Massive trauma.
- Obstetrical emergencies.
- Also during exchange transfusion.
An urgent transfusion is recommended if the loss is more than 40% of the blood volume while in case of blood loss between 30% and 40% of the blood volume presence of signs of inadequate perfusion mandates blood transfusion. The blood transfusion is rarely needed if the blood loss is around 15-30%.
| Packed red blood cells|| |
These are prepared by centrifugation of whole blood from which supernatant (platelet rich plasma) is removed. The clinical characteristics per unit packed red blood cell (PRBC) are:
- Hematocrit of about 55-75%.
- hemoglobin (Hb) of ~20 g/dL.
- Volume ~150-200 ml.
- Stored at 2-6°C.
- Average shelf-life is 21-42 days.
- Should be transfused within 4 h of rewarming to body temperature.
Majority of the patients in ICU with systemic inflammatory response syndrome, septic shock and multiple traumas tend to develop anemia during a prolonged stay in ICU. It is recommended that in absence of cardiac dysfunction or critical coronary artery disease, a Hb concentration of 7-8 g/dL is considered to be safe for adequately meeting the oxygen needs of the body. 
Evidence based recommendations for packed red blood cell transfusions
- In hospitalized patients, PRBC transfusion is required if the Hb level is <7 g/dL and the transfusion can be given in patients with coronary artery disease, chronic renal failure, congestive heart failure etc., even if the Hb is more than 7 g/dL. 
- In peri-operative period, if Hb concentration is <7 g/dL, RBC transfusion is usually required. If Hb concentration is between 7 and 10 g/dL, RBC transfusion may be appropriate if any of the following are present, that is, organ ischemia, increased potential for or ongoing blood loss, volume status and risk factors for complications of inadequate oxygenation. If Hb concentration is more than 10 g/dL then RBC transfusion is usually unnecessary. 
- In cases of bone marrow failure, transfusion is required even if Hb is more than 7 g/dL as a regular predetermined therapeutic program. ,
- In cases of symptomatic anemia with normal blood volume.
| Plasma|| |
Whole plasma is rarely used as such and its use primarily for volume resuscitation and for intravenous (IV) nutrition (protein build up) should not be encouraged.
| Fresh frozen plasma|| |
It is obtained by separating the liquid portion of blood from the cells and rapidly freezing it. The clinical characteristics per unit of fresh frozen plasma (FFP) are:
- Contains stable clotting factors, immunoglobulins (Igs) and albumin.
- Volume is about 200-300 ml/unit.
- Frozen within6 h to -25°C to maintain the coagulation factors.
- Can be stored at −25°C for up to 1 year.
- Thawed at 30-37°C before transfusing.
- Transfusion should be started within 6 h of thawing.
The transfusion practice of FFP remains high with more than 0.5 million units ordered in United Kingdom annually.
Evidence based recommendations for fresh frozen plasma transfusion
- Active bleeding with documented coagulopathy (international normalized ratio INR >2 or prothrombin time (PT) >1.5 or activated partial thromboplastin time (APTT) twice the normal). ,,,
- Liver disease with coagulopathy.
- Emergent reversal of warfarin effect. ,
- Disseminated intravascular coagulopathy (DIC).
- Dilutional coagulopathy due to infusion of large volumes of transfusion.
- Replacement of single factor deficiencies (factor XI, V deficiency).
- Prophylaxis in patients undergoing surgery or invasive procedure with coagulopathy. 
The amount of FFP to be transfused is considered to be about 10-15 ml/kg. The target INR should be <1.7 or PT should be <1.5 or APTT should be less than twice the normal.
| Platelets|| |
The clinical characteristics of pooled platelet concentrate are:
- Pooled platelet concentrates contain 240 × 10 9 platelets (4-6 pooled units).
- Single donor plasmapheresis (most commonly recommended for transfusion) contains at least 55 × 10 9 platelets.
- Stored at 20-24°C with constant agitation for up to 5 days.
- Should be infused within 4 h of collection to avoid contamination.
- Total transfusion time should not exceed 30 min.
Evidence based recommendations for platelet transfusion
- Active bleeding and platelet count <50,000/μl. ,,,,
- Active bleeding and platelet function defect. ,,,,
- Hematology patients with active bleeding: autoimmune platelet disorders, dengue, malaria, kalaazar.
- Oncology patients with: ,
- Platelet count <10,000/μl in stable patients.
- Platelet count <20,000/μl in the presence of risk factors.
- Surgical or invasive procedures with:
- Platelet count <50,000/μl for procedures with minimal bleeding risk.
- Platelet count <100,000/μl for central nervous system, ophthalmological surgery where microvascular Bleeding is hazardous.
- Massive blood transfusion, that is, replacement of whole blood volume within 24 h. 
- Postcardiopulmonary bypass with uncontrolled bleeding. 
The transfusion of 1-2 single donor platelets units is usually adequate to control bleeding (raises count by 20,000-40,000/μl) along with the use of other adjuvants like desmopressin and tranexamic acid, which can also be helpful.
| Cryoprecipitate|| |
It is the fraction of plasma that remains undissolved after controlled thawing of FFP at 4°C. The clinical characteristics of cryoprecipitate are:
- Rich in fibrinogen (150-300 mg/pack), factor VIII (80-100 IU/pack), vonwillibrand factor and fibronectin.
- Resuspended in 10-20 ml plasma.
- Supplied in pack of 6 or more.
- Can be stored at −25°C for up to 1 year.
- Should be infused within 6 h of thawing.
Evidence based recommendations for cryoprecipitate transfusion
- Fibrinogen levels <80-100 mg/dL with bleeding. ,,
- Disseminated intravascular coagulopathy. ,,
- Liver disease. ,,
- Massive transfusion. ,,
- Factor XIII deficiency. ,,
The amount of cryoprecipitate recommended for transfusion is 1 unit per 7-10 kg of body weight (5-10 units in an adult) which is considered to be sufficient to control bleeding.
| Factor concentrates|| |
High cost and difficulty in procuring these products have not popularized individual factor concentrates. Factor concentrates are generally required in hemophiliacs. The incidence of hemophilia is approximately 1 in 5000 males. It has been estimated that in India alone, about 1300 children with hemophilia are born each year, and there are nearly 50,000 patients with severe hemophilia A requiring factor transfusion. ,,,,[ 27]
Classification and clinical utility of factor concentrates
Recombinant or plasma-derived factor VIII
This is recommended in moderate to severe factor VIII deficiency (hemophilia A) and mild factor VIII deficiency unresponsive to desmopressin.
Recombinant or plasma-derived factor IX
It is recommended in patients with factor IX deficiency (hemophilia B).
Activated prothrombin complex concentrates
It is recommended for bleeding episodes or surgical procedures in patients with hemophilia A or B where individual components not available and in nonhemophiliac patients with acquired inhibitors to coagulation factors.
Prothrombin complex concentrate
It is recommended for urgent reversal of warfarin in life-threatening bleeding conditions and in deficiency of other vitamin K-dependent factors in settings where no other concentrate is available (factor X and factor II deficiency).
| Other Infrequently/Rarely Used Specific Blood Products|| |
Leukocyte-reduced or depleted blood products (red blood cells, platelets)
These are prepared by a single upright sedimentation of saline-diluted, 6-10 days old RBC's. These should contain <5 × 10 6 leukocytes. A leukocyte filter may also be used if leukocyte depleted cells are not available. ,,
Evidence based recommendations for transfusions are
- Prevention of febrile nonhemolytic transfusion reactions.
- Prevention of allow-immunization to human leukocyte antigen.
- Prevention of cytomegalovirus infections in patients at risk for CMV transfusion.
Washed red blood cells or platelet
These are produced by washing packed RBCs with 1-2 L of normal saline. The washed units contain 10-20% less RBCs than the original units and have a short half-life of 24 h.
Evidence based recommendations for transfusion is
- History of anaphylactic reaction to blood components
- Immunoglobulin (IgA) deficiency with documented IgA antibody.
- Recurrent severe or allergic reactions not prevented with appropriate premedication.
- Severe hyperkalemia (e.g., neonates, renal failure).
Irradiated blood products
These are indicated for the prevention of transfusion-associated graft versus host disease. These are prepared from plasma of many donors pooled before freeze drying.
| Granulocytes|| |
These are collected from granulocyte-colony stimulating factor stimulated donors consisting of five daily collections. Each unit contains 3-4 × 10 10 granulocytes. These should be irradiated before use. The common indications are severe neutropenia (absolute neutrophil count <500/μl) with reversible marrow hypoplasia and documented bacterial or fungal infection unresponsive to 48 h of appropriate antibiotic therapy and in patients with severe neutrophil dysfunction and bacterial or fungal infection.
Although transfusion can be a life-saving therapy, it is nearly impossible to provide zero transfusion related risk. The benefits of the transfusion should be carefully weighed against the associated risks.
Perioperative blood transfusion management
The perioperative management of transfusion of blood and components is essential for reducing the risk of adverse events associated with transfusion and for adequate utilization of resources. It involves.
The main aim is to identify the patients with an increased likelihood of intraoperative transfusion. These include patients with cardiorespiratory diseases with risk of organ ischemia, coagulopathy, and previous history of drug therapy that is known to affect different aspects of blood hemostasis.
Intraoperative and postoperative management of blood loss
The decision for intraoperative transfusion should be based on monitoring of blood loss by visual inspection of the surgical field and quantitative measurement of suction and surgical sponges, by monitoring vital organ perfusion using the vital signs monitoring and weighing the risks and benefits of transfusion based on the presence of risk factors for the development of organ ischemia.
Another important consideration in the perioperative transfusion management is monitoring and treatment of transfusion related adverse events that range from bacterial contamination to acute lung injury and transfusion related adverse reactions. The management of these transfusion reactions is dealt subsequently. 
Precautions for transfusion
The following precautions should be taken for transfusion of blood and components:
- Blood should be administered within 30 min of issue from the blood bank.
- Unused blood from the theatre or wards should be returned immediately (within 30 min) to the blood bank.
- Always check for ABO and Rh compatibility.
- Never add medications to blood units.
- Change the blood sets at least 12 hourly.
- Complete transfusions in recommended time.
- Do not transfuse a blood bag which appears discolored, has signs of leakage or appears abnormal or damaged.
- Use infusion sets with appropriate filter size.
- Transfuse under supervision of the clinician.
- The final administration check must be conducted next to the patient by a trained and competent healthcare professional doctor/nurse.
- All patients are receiving a transfusion must be properly identified.
- All patient identifiers must match the details on the blood component label.
- Observations should be undertaken for every unit transfused.
All the patients are undergoing transfusion should be monitored at regular intervals by competent health care personnel for the development of any transfusion related adverse effects. The vital parameters monitored should be the pulse, blood pressure, temperature and respiratory rate. The patients should be educated to report any adverse effects both during and after the transfusion. 
Recommendations during transfusion reaction
In case an adverse reaction occurs it is recommended urgently to:
- Stop the transfusion.
- Keep the IV line patent with normal saline.
- Monitor the vital signs of the patient.
- Inform the laboratory about a possible transfusion reaction.
- Check again the clerical information to ensure that the patient is receiving the correct blood.
| Types of adverse reaction to blood products|| |
These are further divided into three categories depending on the severity of reaction. 
It includes localized cutaneous reactions like urticarial, rash, pruritis etc., and is mainly due to mild hypersensitivity.
It includes moderately severe reactions like flushing, urticaria, rigors, fever, restlessness, tachycardia, palpitations, pruritis, headache and mild dyspnea. The possible causes are hypersensitivity, febrile nonhemolytic reactions due to antibodies to leucocytes and platelets and possible contamination with pyrogens and/or bacteria.
It includes life-threatening reactions like fever, rigors, restlessness, hypotension, tachycardia, hemoglobinuria, unexplained bleeding, chest pain, respiratory distress, loin/back pain and headache. The possible causes are:
- Acute intravascular hemolysis.
- Bacterial contamination and septic shock.
- Fluid overload.
- Transfusion related acute lung injury.
- Delayed hemolytic reaction.
- Posttransfusion purpura.
- Graft versus host reaction.
- Iron overload.
- Transmission of infections.
Management of transfusion related reaction
Two blood samples should be taken from the patient, one 10 ml blood sample should be taken from the opposite arm and the plasma should be checked for evidence of hemolysis. Another 2 ml sample should be taken and labeled correctly and should be sent to the laboratory for recrossmatching along with the blood bag with the blood set attached to it. This should be accompanied with the blood requisition form duly filled in indicating that the reaction has occurred. The hospital transfusion committee should also be informed about the reaction. The other steps to be taken depend upon the type of transfusion reaction and are depicted in [Table 1]. ,
| Conclusion|| |
Transfusion of blood and components can be life-saving in some situations but also carries the risk of the various transfusion related reactions as well as transmission of infective diseases. The transfusion should always be performed by competent health care personnel with constant monitoring using the recommendations mentioned. The indications of blood and its components should be strictly adhered to and the transfusion should not occur merely to correct laboratory abnormalities. The decision to transfuse should take into account the clinical scenario of the patient. The protocols for safe transfusion practice should be institutionalized based on the local transfusion practices. In the end, all the health care personals involved in the transfusion practice should be educated about the recognition of the various transfusion related adverse-effects and their prompt management.
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