Clinical Use of Blood Clinical Use of Blood ComponentsComponents

Salwa HindawiSalwa HindawiDirector of Blood Transfusion ServicesDirector of Blood Transfusion Services

KAUH, JeddahKAUH, JeddahKSAKSA

SITMS 24SITMS 24thth March 2004 March 2004

The risks associated with transfusion can be reduced by: - Effective blood donor selection.- Screening for TTI in the blood donor population. high quality blood grouping, compatibility testing. - Component separation and storage.

- Appropriate clinical use of blood and blood products. - Quality assurance

Donor Patient

Blood ProductsBlood Products

Any therapeutic substance prepared from Any therapeutic substance prepared from human blood:human blood:

Whole bloodWhole blood1-Blood components1-Blood components Red Cell Concentrate and suspensionRed Cell Concentrate and suspension Platelet ConcentratePlatelet Concentrate

Plasma – FFP Plasma – FFP CryoprecipitateCryoprecipitate

CryosupernatentCryosupernatent

2-2- Plasma DerivativesPlasma Derivatives

Human plasma proteins prepared from Human plasma proteins prepared from plasma under Pharmaceutical plasma under Pharmaceutical Manufacturing ConditionsManufacturing Conditions• AlbuminAlbumin• Coagulation factors concentratesCoagulation factors concentrates• ImmunoglobulinsImmunoglobulins

Principles of Clinical Principles of Clinical Transfusion PracticesTransfusion Practices

Avoid blood transfusionAvoid blood transfusion Transfusion is only one part of the Transfusion is only one part of the

patient’s management.patient’s management. Prevention and early diagnosis and Prevention and early diagnosis and

treatment of Anemia & underlying treatment of Anemia & underlying conditioncondition

Use of alternative to transfusion.Use of alternative to transfusion.eg. IV fluidseg. IV fluids

Good anesthetic and surgical Good anesthetic and surgical management to minimized blood loss.management to minimized blood loss.

** Prescribing should be based on Prescribing should be based on national guidelines on the clinical use national guidelines on the clinical use of of blood taking individual patient blood taking individual patient needs into needs into account.account.

** Hb level should not be the sole Hb level should not be the sole deciding Factor Clinical evaluation is deciding Factor Clinical evaluation is importantimportant

** The clinician should record the reason for The clinician should record the reason for transfusion clearly. transfusion clearly.

** A trained person should monitor the A trained person should monitor the transfused patient and if any adverse transfused patient and if any adverse effects occur respond immediately.effects occur respond immediately.

WHENWHEN WE SHOULD TRANSFUSE BLOOD ? WE SHOULD TRANSFUSE BLOOD ?&&

WHAT BLOOD WHAT BLOOD COMPONENTCOMPONENT

SHOULD BE TRANSFUSED ?SHOULD BE TRANSFUSED ?

TO TRANSFUSE BLOOD TO TRANSFUSE BLOOD

WHEN WHEN

NECESSARYNECESSARY

Unnecessary transfusion canUnnecessary transfusion can : :

Expose the patient to unnecessary Expose the patient to unnecessary risksrisks

Cause a shortage of blood products Cause a shortage of blood products for patients in real need.for patients in real need.

Blood is an expensive, scarce Blood is an expensive, scarce resource.resource.

The lowest threshold for transfusion of The lowest threshold for transfusion of components are:components are:

Hb level of 6-7g/dl. Clinical judgmentHb level of 6-7g/dl. Clinical judgment FFP threshold PT & PTT 1.5 times the FFP threshold PT & PTT 1.5 times the

upper limit of the normal range. upper limit of the normal range. Platelet threshold of:Platelet threshold of:

10 000/µl- 20 000/µl for prophylactic 10 000/µl- 20 000/µl for prophylactic transfusiontransfusion

Triggers of Component Triggers of Component TransfusionTransfusion

Invasive or surgical procedures:Invasive or surgical procedures:

20 000/20 000/µl for BMA and Biopsyµl for BMA and Biopsy

50 000/µl for surgery, massive 50 000/µl for surgery, massive transfusion, transfusion, Liver cirrhosis.Liver cirrhosis.

100 000/µl for surgery to brain or eye100 000/µl for surgery to brain or eye..

American Society of clinical Oncology guidline,1996&2001.American Society of clinical Oncology guidline,1996&2001.

Williamson LM. Transfusion Trigger in the UK. Vox sang Williamson LM. Transfusion Trigger in the UK. Vox sang 2002.2002.

AABB Technical Manual 14AABB Technical Manual 14thth ed, 2002. ed, 2002.

Evidence based medicine through Evidence based medicine through randomized controled trials and or randomized controled trials and or

clinical practiceclinical practice

The use of a 7g/dl Hb threshold in critical careThe use of a 7g/dl Hb threshold in critical carepatients with maintenance of Hb of 7-9g/dlpatients with maintenance of Hb of 7-9g/dlresulted in a 54%decrease in the number ofresulted in a 54%decrease in the number oftransfused red cells and decrease exposure totransfused red cells and decrease exposure toany red cell by 33%.any red cell by 33%.

Hebert ,et al. N Engl J Med 1999

255 patients with acute myeloid leukemia 255 patients with acute myeloid leukemia Evaluated prospectively:Evaluated prospectively:

135 patients were assigned to 10 000/mm135 patients were assigned to 10 000/mm33 threshold groupthreshold group

120 were assigned to 20 000/mm120 were assigned to 20 000/mm33

The risk of major bleeding was similarThe risk of major bleeding was similar Platelet use reduced by 21.5% in the lower Platelet use reduced by 21.5% in the lower

threshold group threshold group

Rebulla et alRebulla et al.N Engl J Med 1997.N Engl J Med 1997..

The Appropriate Use of Blood The Appropriate Use of Blood and Blood Productsand Blood Products

Safe Product (Supply safe accessible at Safe Product (Supply safe accessible at reasonable cost, adequate)reasonable cost, adequate)

Weight the risk against benefitWeight the risk against benefit

ALTERNATIVES TO BLOOD ALTERNATIVES TO BLOOD TRANSFUSIONTRANSFUSION

CRYSTALLOID SOLUTIONSCRYSTALLOID SOLUTIONS COLLOID SLOUTIONSCOLLOID SLOUTIONS DRUGSDRUGS BLOOD SUBSTITUTESBLOOD SUBSTITUTES

Guidelines on:Guidelines on: Ordering Blood Ordering Blood IndicationsIndications Compatibility policy differ from center to Compatibility policy differ from center to

anotheranother Collecting blood products prior to Collecting blood products prior to

transfusiontransfusion AdministrationAdministration Monitoring the transfusion Monitoring the transfusion Adverse effect of transfusionAdverse effect of transfusion

Surgery Surgery Infection ControlInfection Control Transfusion specialist Transfusion specialist

or Haematologistor Haematologist PediatricsPediatrics ObstetricsObstetrics AnesthesiaAnesthesia MedicineMedicine Nurse Nurse QAQA

The committee shall be The committee shall be responsible forresponsible for::

Developing the guidelines for transfusionDeveloping the guidelines for transfusion

Reviewing of the use of blood and its Reviewing of the use of blood and its componentscomponents

Reviewing structure, process , outcomes Reviewing structure, process , outcomes and utilization Indicators.and utilization Indicators.

Reviewing all reports regarding Reviewing all reports regarding transfusion reaction & Incident reportstransfusion reaction & Incident reports

Promote education and training of all Promote education and training of all clinical and support Staff involved in clinical and support Staff involved in blood transfusion.blood transfusion.

Have the authority to modify and Have the authority to modify and implement the existing Blood implement the existing Blood transfusion protocolstransfusion protocols

MSOS is a table of elective surgical MSOS is a table of elective surgical procedures that lists the number of units of procedures that lists the number of units of blood routinely cross-matched pre-blood routinely cross-matched pre-operative.operative.

The ideal value for cross matched to The ideal value for cross matched to transfused blood, C:T ratio is 1:1 .transfused blood, C:T ratio is 1:1 .

An acceptable value is 3:1 - 2:1 which An acceptable value is 3:1 - 2:1 which corresponds to a blood usage of 30-50%.corresponds to a blood usage of 30-50%.

Maximum Surgical Blood Ordering Maximum Surgical Blood Ordering Schedule (MSOS)Schedule (MSOS)

AdvantagesAdvantages A reduction in cross-matching workload, A reduction in cross-matching workload,

which allows more time to respond to which allows more time to respond to emergency requests and to investigate emergency requests and to investigate complex serological problems.complex serological problems.

A reduction in the level of stress and A reduction in the level of stress and wastage of reagents.wastage of reagents.

More efficient use of blood stocks and a More efficient use of blood stocks and a reduction of wastage due to outdating.reduction of wastage due to outdating.

Cost-effective.Cost-effective.

A checklist for cliniciansA checklist for cliniciansAlways ask yourself the following questions Always ask yourself the following questions

before prescribing blood or blood before prescribing blood or blood products for a patientproducts for a patient

What improvement in the patient's clinical What improvement in the patient's clinical condition am I aiming to achieve? condition am I aiming to achieve?

Can I minimize blood loss to reduce this Can I minimize blood loss to reduce this patient's need for transfusionpatient's need for transfusion

Are there any other treatments I should give Are there any other treatments I should give before making the decision to transfuse, before making the decision to transfuse, such as intravenous replacement fluids or such as intravenous replacement fluids or oxygen? oxygen?

What are the specific clinical or laboratory indications for What are the specific clinical or laboratory indications for transfusion for this patient?transfusion for this patient?

What are the risks of transmitting HIV, hepatitis, syphilis or What are the risks of transmitting HIV, hepatitis, syphilis or

otherother

Infectious agents through the blood products that are Infectious agents through the blood products that are availableavailable

What other options are there if no blood is What other options are there if no blood is available in time?available in time?

Will a trained person monitor this patient and Will a trained person monitor this patient and

respond immediately if any acute transfusion respond immediately if any acute transfusion reactions occur? reactions occur?

Have I recorded my decision and reasons for Have I recorded my decision and reasons for transfusion on the patient's chart and the blood transfusion on the patient's chart and the blood request form? request form?

Finally, if in doubt, ask yourself the Finally, if in doubt, ask yourself the following question.following question.

If this blood was for myself or my child, If this blood was for myself or my child, would I accept the transfusion in these would I accept the transfusion in these circumstances?circumstances?

Conclusions 1Conclusions 1

Availability of safe blood Availability of safe blood

Evidence-based clinical guidelines Evidence-based clinical guidelines for usage of blood &blood products.for usage of blood &blood products.

Correct management of blood Correct management of blood inventory to prevent blood units inventory to prevent blood units wastage & outdating.wastage & outdating.

Promotion of blood component Promotion of blood component therapy.therapy.

ConclusionsConclusions 22

Hospital transfusion committee.Hospital transfusion committee.

Training & education for laboratory Training & education for laboratory staff , students & treating staff , students & treating physician.physician.

Availability and accessibility of Availability and accessibility of blood blood substitutes. substitutes.

Auditing Auditing

ReferencesReferences

The Clinical use of Blood Handbook, The Clinical use of Blood Handbook, WHO Blood Transfusion safety, WHO Blood Transfusion safety,

GenevaGeneva

AABB technical Manual 14AABB technical Manual 14thth Edition Edition 2002.2002.

Handbook of transfusion Medicine Handbook of transfusion Medicine 3rd 3rd editionedition