Blood products

1. BLOOD & BLOOD PRODUCTS

2. GOALS
1. To know variety of blood products
2. To know right time and indications to start blood or
blood products transfusion
3. To know the complications of massive transfusion

3. PREGNANCY & BLOOD LOSS
 Pregnant women has an increased blood volume
of about 20-30%
 Blood volume estimation - about 100ml/kg
 60kg = 6 litres of blood
 As such
 1.0L of blood loss in a pregnant woman is not the same as
1.0L of blood loss in a non-pregnant woman
 1.0L of blood loss in a 80kg woman is different from a 40kg
woman

4. CHANGES IN VITAL SIGNS WITH BLOOD LOSS

5. VITAL SIGNS
 When abnormal in the context of haemorrhage, they are
useful in assessing the severity of the hypovolemic shock
 When normal however, they are not reliable in assessing
the severity of the hypovolemic shock
 Remember that a drop in BP is a late sign of hypovolaemia!
Patient has lost at least 30% of her blood volume!!!
 Should not rely on BP to assess volume loss!!!

6. LOSS OF CIRCULATING VOLUME
 Replacement with crystalloids - every ml blood loss, 3ml
crystalloids needed
 3 to 1 ratio
 Replacement with colloids – every ml blood loss, 1.5 ml
colloids needed
 3 to 2 ratio

7. VARIETY OF BLOOD COMPONENTS
 Whole blood
 Red blood cells
 Packed cells
 Platelet
 Fresh frozen plasma
 Cryoprecipitate

8. VARIOUS BLOOD PRODUCTS
Blood products Volume
(ml/unit)
Contents Effects Compatibility
Packed red cells 280 +/-
50
RBC, WBC,
plasma
Increase HCT
by 3%, increase
HB by 1gm/dL
ABO and RH
Platelets 50 +/- 10 PLT, RBC, WBC,
plasma
Increase PLT
between 5-10 x
109/L
ABO and RH
Fresh Frozen
plasma (FFP)
200 – 250 One IU/ml of all
coagulation
factors; 400mg of
fibrinogen per
unit
Increase
fibrinogen by
10mg/dL
ABO, no need RH
compatibility
Cryoprecipitate 40 +/- 10 Fibrinogen,
factorsVII, III, XIII,
VonWillerbrand
factorFibrinogen,
factor VIII, XIII,
Von Willebrand
Increase
fibrinogen by
10mg/dL
ABO, no need RH
compatibility

9. INDICATION FOR TRANSFUSION – WHOLE BLOOD
 Whole blood vs Packed cells
 No data to suggest that the use of whole blood, even
“fresh” is associated with better outcome in acute blood
loss
 Usually used in exchange transfusion
 For acute blood loss
 Give specific blood components as required:
 Packed cells
 Platelet concentrate
 FFP
 Cryoprecipitate - Factor I, VIII, vWF (+ XIII, fibronectin)
 Cryosupernatant

10. INDICATION FOR TRANSFUSION – RED CELLS
 Acute blood loss
 Based on haemoglobin concentration
 Hb > 10 g/dl – not indicated
 Hb < 7 g/dl – indicated
 Hb 7 – 10 g/dl – less clear; depends on situation and patient
 Based on risk of further blood loss

11.  Based on estimation of blood loss
Circulating
volume lost
Signs Replacement
15%
(750 mls)
Mild increase in PR -
15 – 30%
(800 – 1500
mls)
Increase PR
Increase breathing
Use crystalloids or colloids to
replace fluid loss
30 – 40%
(1.5-2.0L)
Increase PR
Increase breathing
Fall in BP
Use crystalloids or colloids to
replace fluid loss
Red cells transfusion likely be
required
>40%
(Over 2 L)
Immediate life threatening Blood transfusion is required
immediately
Need rapid transfusion

12. Major problem!!!!!
Underestimation of blood lost often
happens!!
Therefore, clinical signs of shock are
important

13.  Other indications
 Perioperative haemoglobin optimisation
 Chronic anaemia
 Anaemia in critical care

14. RAPID BLOOD TRANSFUSION IN LIFE
THREATENING CONDITION
 BP cuff (high-pressure infusion devices)
 No blood filters
 With warmers
 O-ve or O +ve blood
 Unmatched blood

15. INDICATION FOR TRANSFUSION OF OTHER
BLOOD PRODUCTS
 Platelet
 In DIVC or at platelet transfusion trigger of 75,000/l
 Fresh frozen plasma and cryoprecipitate
 In DIVC (evidenced clinically or from coagulation
screen) with evidence of bleeding
 There is no evidence for prophylactic FFPntransfusion
to prevent DIVC or to reduce transfusion
 In massive transfusion
 FFP should be administered for every 6 units of red cells
transfusion; aim to maintain APTT < 1.5
 Cryoprecipitate should be administered early in major
obstetric haemorrhage to keep fibrinogen > 1.5 g/l

16. DIVC IN OBSTETRICS
 Consumption coagulopathy (depletion of platelets and
coagulation factors) that leads to further haemorrhage
 Can be due to:
 Massive bleeding (e.g. APH, PPH, abruption)
 Sepsis
 Amniotic fluid embolism
 Eclampsia
 IUD

17.  Treat the underlying cause (sepsis, massive blood loss,
severe vessel injury, toxins)
 Transfuse platelet if bleeding associated with
thrombocytopaenia. Aim for > 50 x 109 /L (C, IV)
 Platelets should not be allowed to fall <50 x 109 in acutely
bleeding patient

18.  If bleeding continues after large volumes red cell and
platelets have been transfused, FFP and cryoprecipitate
may be given (depending on protocol e.g. after 10 units
of RBCs, abnormal coagulation profile, etc)
 Transfuse FFP and cryoprecipitate so that the PT and
APTT ratios are within 1.5 and a fibrinogen level of > 1.0
g/ L

19.  Adequate resuscitation from shock - most
important in preventing coagulopathy
 No evidence that prophylactic regimes prevents
or reduce transfusion requirements

20. DIVC REGIMES??
 Various regimes depends on hospital protocol
 Need to contact Transfusionist medicine specialist for
MTP (Massive blood transfusion protocol)
 Depends on patient’s body weight and also clinical
situation
 NO LONGER 6U FFP, 4U Platelet, 2U cryopercipitate

21. THERAPEUTIC AIMS OF MANAGEMENT
FACTOR AIMS
1. HB > 8 g/dL
2. Platelet > 50K
3. PT/ PTT ratio < 1.5
4. Fibrinogen level > 1.0 g/dL
Adapted from Malaysian CPG on blood transfussion

22. MASSIVE BLOOD LOSS
 Replacement of total blood volume (5 L) within 24 hours
 Loss of 50% blood volume in less than or equal to 3
hours
 150ml/ min blood loss (Loss of half the blood volume in
20 minutes)
 Transfusion of more than 20 units of erythrocytes

23. COMPLICATIONS OF MASSIVE TRANSFUSION
 Hypothermia
 Acid-base disturbance – metabolic alkalosis > acidosis
 Thrombocytopenia & reduced factor I,V,VIII
 Electrolyte imbalance
 Hypokalemia > Hyperkalemia
 Hypocalcemia & citrate intoxication