Blood & Blood Products

Homologous & Autologus Blood

Transfusion

Dr . Prasad Ingley.
Junior Resident I I
NKP Salve Institute of Medical Sciences & L.M.H.
Nagpur, India.
 Historical Aspects
People have always been fascinated by blood,

• Ancient Egyptian bathed in it.

• Aristocrats drank it.

• Authors & playrights used it as themes.

• Modern Humanity transfuse it.

 HISTORY

• 1492 – Blood was taken from three young

men & given to Pope Innocent VII to cure him.

• 1616 - William Harvey ,described how blood

is circulated throughout the body.

• 1667 - First successful human blood

transfusion.
 HISTORY
• After much research, saline was developed as
a plasma volume expander.

• Significant breakthrough - 1883 – creation of

Ringer‘s solution.

• World War I, a gum-saline solution containing

galactoso- gluconic acid was used to extend
plasma - had some negative health effects.
 Why did success elude
experimenters so long ?
Clotting was the principle obstacle to overcome.
overcome

• Braxton Hicks 1869 – Sodium Phosphate as a

nontoxic anticoagulant.

• Karl Landsteiner 1901 – ABO blood gr. System.

• World War II - establishment of blood banks by

the American Red Cross in 1947.
 Approved Anticoagulant
Preservative Solutions
Storage Time
Name Abbreviation Days
• Acid – citrate – dextrose ACD 21
• Citrate-phosphate - dextrose CPD 21
• Citrate-phosphate - dextrose-
adenine CPDA-1 35

• Citrate-phosphate - double
dextrose CP2D 21
 Preparation of blood
components is possible due to
• Multiple plastic packs systems.
• Refrigerated centrifuge.
• Different specific gravity of cellular components:

RBC – 1.08 -1.09

Platelets - 1.03 – 1.04

Plasma - 1.02 -1.03

Classification of Blood Products:

• Whole Blood

• components - Cellular
-Plasma

• Plasma derivatives
 Blood Component

A Constituent separated from

whole blood, by differential
centrifugation of one donor unit or
by aphaeresis.
 Cellular components

• Red cell concentrate.

• Platelet concentrate.

• Granulocyte concentrate.
 Plasma Components

• Fresh frozen plasma (FFP)

• Cryoprecipitate
 Plasma Derivatives

• Albumin 5% & 25%

• Plasma Protein Fractions.
• Factor VIII concentrate.
• Immunoglobulins.
• Fibrinogen.
• Other coagulation factors.
 WHOLE BLOOD

Fresh blood
( Blood less than 24 hrs old )

• Premature newborns with respiratory distress syndrome and

severely decreased 2,3 – DPG levels.

• Patients who are persistently hypotensive, poorly perfused, &

acidotic and who need large amount of blood.
 Whole Blood (CPDA-1)
Blood collected into an approved container containing an
anticoagulant preservative solution.
Total Volm- 350 ml. of whole Blood & 49 ml. Anticoagulant.

Hb approximately 12 g/ml.
Haematocrit 35% - 45%.

No functional platelets .
No labile coagulation factors (V & VII)
Shelf live 35 days in (CPDA-1)

Storage :-

Betn + 20c and + 60c in approved blood bank refrigerator,

fitted with a temp.chart & alarm.
 Indications :-

• Red cell replacement in acute blood loss with hypovolaemia.

• Exchange transfusion.
• Pts needing red cell transfusions where red cell concentrates
or suspensions are not available.

Administration:
• Must be ABO & Rh-D compatible with the recipient.
• Never add medication to a unit of blood.
• Complete transfusion within 4 hrs. of commencement.
 What are the changes which
occur in stored Blood
• Loss of viability of RBCS.

• Loss of ATP.

• Depletion of 2-3 DPG.

• Loss of granulocyte function.

• Decrees in pH of blood.

• Increase in plasma K+ Level.

• Decrease in factor VII level.

• Formation of microaggregates.
 WHOLE BLOOD

• Effects:
1 unit of whole blood ( 350ml) - ↑ Hb by
about 0.75 gm/dl.
( 450ml) - ↑ Hb by
about 1 gm/dl.

In pediatric patients, 8ml/kg of W.B. -↑ Hb by

about 1 gm/dl.
 Red Cells

• Packed Red Cells

• Red Cells in additive solution

• Leucocyte Poor red cells

• Washed red – Cells

• Frozen red Cells

• Irradiated red cells.

 Red Blood Cells

• Hb < 6 gm/dl in the absence of disease.

• Hb between 8-10 gm/dl with disease.

 Red Blood Cells

Indications-
• ↓B.M. production - Leukemia.
- Aplastic anemia.
• ↓ RBC survival - Hemolytic anemia.
-Thalassemia

• Excessive Bleeding -surgical (anticipated blood loss>1000ml)

-traumatic .

• Others - Anemia associated with incipient

/established cardiac failure.

-Full term pregnancy with Hb value

<7 gm/dl.
 Red Cell concentrate
(Packed red Cell, Plasma reduced blood)

Red Cells from which most of Plasma removed.

removed

• 250 ml packed red Cells (150ml red cells + 100 ml Plasma)

• Hb appro. 20g/100ml (Not less than 45 g\unit)
• Haematoerit 55% -75%
• Raises Hb by 1 Gm% & heamatocrit by 3% (Rise detected
after 24 hours.)
• Storage temp 2-60c
• Shelf life 35 days in CPDA -1

Indications : Replacement of red cells in anemic patients.

Acute& massive blood loss(along with crystalloid or colloid)
 Red Cell suspension
(Red cells in additive solution)

Commonly used additive solution is SAGM (Saline, adenine, glucose &

mannitol)

•150-200 ml red cells with minimal residual plasma.

• Hb approx. 15gm/100ml
• Haematocrit 50% - 70%.

Advantage of this method

• Max amount of plasma removed for preparation of plasma
components.
• Red cells with improved viability obtained, shelf life
increases from 35 to 42 days.
• Flow of infusion is improved due to reduction in viscosity.

Contraindicated for exchange transfusion in neonate.

 Leucocyte – poor depleted red cells
A red Cell suspension or containing less than 5*106 white cells/bag, prepared
by filtration through a leucocytes depleting filter.

•Hb & haematocnt depend on whether the product is whole blood,

red cell concentrate or red cell suspension.
•Leucocyte depletion significantly reduces the risk of transmission
of CMV.
Indications:
•To avoid sensitization to HLA antigen in patients with severe
aplastic anaemia who are likely to receive allogenic bone marrow
transplant.
•Patients who have experienced two or more previous febrile
reactions to red cell transfusion.
•To reduce the risk of transmission of CMV.
 Washed red cells
•Packed red cells can be washed with normal saline to remove
plasma proteins, white cells & platelets.

•Use of such red cells is restricted for IgA – deficient individuals

who have developed anti IgA antibodies.
 Frozen red cells
•Red cells can be stored frozen upto 10 years.
•To prevent haemolysis of red cells during freezing & thawing , a
cryoprotective agent such as glycerol is added.

•Donor red cells with rare blood groups can be stored frozen.

•Red cells can be stored frozen for further autologous transfusion

if blood group is rare.
•Before transfusion red cells are thawed & glycerol removed
gradually.

•Such red cells are virtually free from leucocytes, platelets &
plasma & thus their use is associated with lower risk of non-
haemolytic transfusion reactions.
 Irradiated Red Cells

•Transfusion of gamma irradiated red cells is indicated for

prevention of graft Vs host disease in susceptible individuals like
• Immunodeficient ,
• Patients receiving blood from first degree relatives.

Lymphocytes from donor blood react against the tissues of the

recipient .

Gamma irradiation (25-30 Gy) inhibits replication of donor

lymphocytes.
 Advantages of transfusion of red
cells over Whole blood
• Reduce risk of circulatory overload.

• Less severity & incidence of allergic reactions.

• ABO antibodies are reduced.

• Removed plasma can be used for preparing

FFP & Cryoprecipitate
 Platelets

Two Methods :
• Differential centrifugation of a unit of whole
blood.
( Platelet concentrate )
• Plateletpheresis
 Storage

• Up to 72 hours at 20 – 240c with constant agitation.

• Max. period of storage is 3 to 5 days.

• Must not be refrigerated as this will reduce platelet

function.
 Platelet concentrate

Indications
• Platelet count <5000 / µl regardless of clinical condition.

• Platelet count 5000 -10000/ µl- if there is increased risk of

bleeding
• Platelet count 10,000 -20,000/ µl- if thrombocytopenic
bleeding.
• PC <20,000/ µl- if decreased production – chemotherapy.
Risk of bleeding – prophylactically.

• < 50,000/ µl- if ↑ destruction (DIC)

• <50,000/ µl- if Platelet dilution (massive T/F)
• < 70-80,000/ µl- major surgery
 Platelet concentrate

• Dosage :
1 unit /10kg body weight (The usual dose is 4-6 units)
or
1.50 units/10kg body weight in cases of Increased
destruction of platelets.
• Single donor unit in a volume of 50-60 ml of plasma
should contain
a) At least 55 ×109 platelets
b) < 1.2 ×109 red cells
c) < 0.12 ×109 leucocytes.
• Pooled unit should contain at least 240 ×109 platelets.
 Platelet concentrate
• ABO compatibility between donor &
recipient is of minor importance in platelet
transfusion.

• Rh (D) negative female patient of child

bearing age should be given platelets from
Rh (D) negative donor.
 Platelet concentrate
• effect- (by the clinical results & platelet count obtained 1 hr
later)
each unit of P.C. will raise platelet count approximately by –

• Adults : ( 5000 -10000/ µl.) in 70 kg weight.

• Child : (20000/ µl ) in 18 kg body weight.

• Infants : (75000-100000/ µl ).
 Platelet concentrate
• Risk associated with platelet transfusion :

-Alloimmunisation.

-Platelet refractory state (less than 20 % of the expected

increase).

-Infections.

-Graft versus host disease

 Plateletpheresis
• A portion of donor’s platelet and some plasma is
removed with the return of donor’s RBCs, WBCs
and remaining plasma.

• A routine procedure takes 1 to 1.5 hours.

• The product is prepared in closed system and can

be stored for 5 days.
 Relative merits of plateletpheresis
and random donor platelet
Plateletpheresis Random donor platelet
•Average > 3x1011 platelets •5.5 x1010 platelets
•Plasma volume 200 ml •50-60 ml
•Leucocytes < 5.5 x 106 •108 in each unit, filtration is
obviate the need of filtration required
•Red cells- traces •More
•pH- 6.0 or more •pH- 6.0 or more.
•Exposes a patient to one donor •Exposes a patient to multiple
donors.
•Less exposure to infections •More exposure to infections
 Fresh frozen plasma

Indications :
• Congenital or acquired coagulation factor deficiency
with - Active bleeding
Liver disease, DIC, Coagulopathy in massive
transfusion.
• Deficiency of factors II, VII, IX & X.
• Warfarine over dose reversal.
• Thrombotic thrombocytopenic purpura.
 Fresh frozen plasma
Dosage
15ml/kg of body weight (thawed at 30 -370 C)

Compatibility test- is not necessary.

Rh positive plasma should not be given to Rh negative

women in the reproductive age group.
Effect
By APTT , PT & fibrinogen assay.
 Difference Between Apheresis FFP And Whole-
blood Derived FFP

AFFP WBD-FFP
Total volume 540 ml 200 ml
Absolute plasma 486 ml 160 ml
Anticoagulant 4% sodium citrate 3% sodium citrate
CPD/CPDA1
Anticoagulant/ plasma 1:10 1:5
Citrate/100ml plasma 0.4 g 0.6 g
Glucose 100mg/dl 400-715 mg/dl
Cryoprecipitate More Less
Residual platelet & Less than WBD-
WBCs FFP
 Cryoprecipitate

• Prepared by slowly thawing 1 unit of FFP at 4-60 c &

then resuspending it in 10-20 ml plasma.

• The unit is then refrozen -250 c or cooler & can be stored

for 1 year at this temp.

• Contains
factor VIII 80 – 100 iu/pack
Fibrinogen 150 – 300 mg/pack.
Factor XIII & fibronectine.
 Cryoprecipitate
(factorVIII, fibrinogen , Von-Willebrands factor,

Fibronectin & factor XIII)

Indications :
• Haemophilia A
• Von Willebrands disease.
• Congenital or acquired fibrinogen deficiency.
• Acquired factor VIII deficiency.
• Factor XIII deficiency.
• Source of fibrin glue used as topical haemostatic
agent.
 Plasma Derivatives
Human Albumin solutions:

• Albumin prepared by cold ethanol fractionation of pooled

plasma.

• Available as 5%,20%,25% solutions.

• Albumin solutions are heat treated at 600 c for 10 hours.

 Factor VIII Concentrate

• F VIII concentrate prepared by fractionation from large pools

of donated plasma.

• Treated with heat or chemicals to destroy lipid enveloped

viruses.

• Stored at 2 to 60 c.

• Vials freeze dried protein labelled with content, usually about

250 iu of F VIII / vial.
 Factor IX Concentrate
• Both plasma derived & recombinant F IX concentrate are
available for treatement of Haemophilia B.( Christmas
disease ).

• Unit of issue : Vials of freeze dried protein labelled with

content,usually about 350 – 600 iu of Factor IX.
 Prothrombin Complex
Concentrate (PCC)

• Contains F II , IX , X & sometimes also F VII.

• Immediate correction of prolonged PT.

• Contraindicated in patients with liver disease &

thrombotic tendancy.
 Must before transfusion
• Disposable sterile transfusion sets.
• 170 to 200 micron filters.
• By physician or qualified nurse
• Blood grouping.
• Cross – matching & compatability testing.
• Inspection of blood / blood product bag.
 Time limit for the infusion

• Whole blood or packed cells – start within 30 minutes &

complete within 4 hours.

• Platelet concentrate – As soon as received and complete

within 15 – 20 minutes.
Do not put in refrigerator.

• Fresh frozen plasma – As soon as possible after thawing

& complete within 15 – 20 minutes.
 Monitoring the transfused patients

• Before starting the transfusion.

• As soon as the transfusion is started.

• For 15 minutes after starting transfusion.

• At least every hr during transfusion.

• On completion of transfusion.

• 4 hours after completing transfusion.

 Monitoring the transfused patients

For-

• Patient’s general appearance.

• Temperature, BP, Respiratory rate.
• Signs of any adverse reactions –
• Fever with back pain (Acute Hemolytic T.R.)
• Anaphylaxis, hives or pruritis (urticarial reaction )
• Congestive heart failure (Volume overload )
• Fever alone (Febrile non hemolytic T.R.)
 Precautions during Infusion

• Only isotonic saline ( 0.9 %) or 5 % albumin can

be used to dilute blood component.

• Blood Warming is not required :

Infusion of 2-4 units of refrigerated blood over several
hours causes no harm.
 Who needs Warm Blood?

• Adults receiving multiple transfusion

at rate >50 ml/ kg/hr.
kg/hr
• Children receiving transfusions
at rate >15 ml/ kg/hr.
kg/hr
• Infants receiving exchange transfusions.
• Patients receiving rapid transfusion through
central venous catheter.
• Patients with cold agglutinins.
 TRANSFUSION REACTIONS

• Category I – Mild reactions.

Symptom Possible cause Management

& signs

Itching, Hypersensitivity -Slow the t/f

rashes -Antihistaminics
 TRANSFUSION REACTIONS
Category II – Moderate reactions.

Symptom & Possible Management

signs Causes

Anxiety, Hypersensitivity, Stop t/f, keep IV

itching, FNHTR- line open, inform,
flushing, Ab- WBCs/ send blood unit to
rigor, fever, platelets/proteins bank with fresh
palpitation blood and urine
(IgA),
headache, contamination samples,
dyspnoea, antihistaminic,
tachycardia steroids,
bronchodilator
 TRANSFUSION REACTIONS
Category III – Life threatening .
Symptom & Possible causes Management
signs
Chest pain, Acute hemolysis, With measures in
pain at t/f bact. Contamination, catg. II-
site, resp. fluid overload, Maintain air way,
distress, low anaphylaxis, oxygen, adrenalin,
back pain, TRALI. diuretics, steroids,
fever, fluid balance,
tachycardia
DIC- platelets
hypotension,
red urine, Hypotension-
DIC dopamine
Infection- antibiotics
 MASSIVE BLOOD TRANSFUSION
• This is defined as the transfusion of the equivalent of the the
circulating blood volume within a 24hour period (in practice 10-
20 units in an adult)

• Common identifications for massive blood transfusion are major

trauma, gastrointestinal bleeding and obstetrics complications.
 Massive Transfusion Guidelines

Criteria for Activation of the MTG:

• 1. Adult patients requiring > 4 units of PRBCs in first hour of
resuscitation or pediatric patient requiring > 20 ml/kg of
PRBCs in first hour of resuscitation.

• 2. Adult patients with the high likelihood of requiring

transfusion of > 10 units of PRBCs within the first 12 hours
of resuscitation or pediatric patient with the high likelihood of
requiring transfusion of > 0.1 units/kg of PRBCs within the
first 12 hours of resuscitation.
Major problems associated with massive blood transfusion
include,
•Citrate toxicity & hypocalcemia.
•Acidosis.
•Underlying coagulopathy.
•Dilutional thrombocytopenia.
•Lack of coagulation factor 5 & 8 & fibrinogen.
•Hyperkalaemia.
•Hypothermia.
•Microaggregates
Management of a patient who is bleeding
 Algorithm for diagnosing & treating a massive blood loss

From blood sample

CBC,PC,PT,PTT, FIBRINOGRN
Blood to lab 4
units PRBC in ED
Indications for type O
NO blood :BP<70 mmHg
Indication for Crystalloid + re-evaluate
immediate transfusion
Indications for transfusion protocol
YES BP<90 mmHg .
Give 2 units PRBCS
NO Crystalloid + bl .by lab values Blood loss=circulating volume.
YES
Review lab results YES Give 4 units of FFP & Monitoring protocol
Coagulopathy present? 6 packs of platelets HCT,PT,PTT,PC,

NO
HCT < 30 % ?
YES Give whole blood or
Transfusion thresholds
PRBCS to HCT 30
NO HCT,PT,PTT, INR>2.0 Usually.
PC<75,000,Fibrinogen<100mg/dl
PT > transfusion
threshold?
NO
Give 6 packs of platelets to
PC < transfusion threshold? YES PC 25-50,000
NO
Anticipated ongoing
blood loss Transfuse to maintain thresholds:
NO HCT<30% FFPwith PC ratio of
1:1 Platelates with PC in ratio 1:1
De-activate massive
transfusion protocol
 METHODS FOR REDUCED BLOOD
USE IN SURGERY
• PREOPERATIVE
* Surgery elective – Correct the Haemoglobin level.
Stop drugs that interfere Haemostasis
• INTRAOPERATIVE
– Posture
– Use of Vasoconstrictors
– Use of tourniquets
– Use of anti-fibrinolytic drugs eg Aprotinin
– Using Fibrin Sealant

• POST OPERATIVELY
– Blood can be salvaged from drains into collection devices that permit
reinfusion

– Decision to transfuse post operatively should depend

* Age of the patient
* Ability to tolerate lower levels of anaemia
* Rate & amount of continuing blood loss
 Pediatric Transfusion
• RED CELLS - 10 – 15 ml/kg.
• PLATELETS - 5 - 10 ml/kg.
• FFP - 10 – 15 ml/kg.
• CRYOPRECIPITATES – 1- 2 unit/kg.
Autologous Blood
transfusion
 Definition

Autologous blood transfusion is the collection

and reinfusion of patient’s own blood or
blood components.
 Autologous
Blood Transfusion

• Pre-surgical Autologous Blood

Donation.

• Normovolemic Haemodilution.

• Intraoperative Cell Saver.

• Postoperative Blood Salvage.

 Why Autologous Blood Transfusion?
• Fully compatible blood.

• No risk of transfusion transmitted diseases such as hepatitis,

CMV and HIV infection.

• Avoidance of allo-immunization.

• Avoidance of GVHD.

• Improved O2 perfusion by lowering blood viscosity.

• Acute Normovolemic Hemodilution provides fresh whole blood.

• Less dependant on the blood bank’s stock.

 Why Autologous Blood Transfusion

•Readily available in major haemorrhage

•Avoidance of immuno-suppression

A Clinical and Immunologic Study of

Blood Transfusion and Postoperative Bacterial Infection in Spinal
Surgery

A marked reduction in the hospital infection rates,

antibiotic usage and length of hospital stay in patients
who received autologous blood or no blood.

Triulzi et al, Transfusion 1992;32:517-524

 Disadvantages

1 Same risk of bacterial contamination.

2 Same risk of ABO incompatibility error.
3 Costlier than allogenic blood.
4 Wastage of blood, if not switched over.
5 Chances of unnecessary transfusion.
6 Subjects patient to perioperative anemia
& increase likelihood of transfusion.
 Pre-surgical
Autologous Blood Donation

• Concept :
Blood can be collected ( single unit or serial collection)
well in advance from patients undergoing major surgery.

• The technique is used only for surgical procedures where

likelihood of blood transfusion is more.

• PABD does not completely eliminate the possibility that

the patient might receive allogenic blood.
 Selection of patients
• Elective surgery that can be scheduled at least several weeks
in the future.

• A surgical procedure for which blood is usually crossmatched.

• Hb > 11gm/dl , hematocrit 33%.

• No age or weight limit.

• Proposed surgery protocol should include requirement of blood.

• Maximum collection amount is 10.5ml / kg excluding sampling

amount.
• Donation may be more than once a week
but last should occur no less than 72 hrs
before surgery to allow time for restoration
of intravascular volume and for transport
and testing of the donated blood.
 Testing of Pre-surgical
Autologous Blood

All autologous blood should be tested

the same ways as for allogeneic blood

•Human Immunodeficiency Virus (HIV)

•Hepatitis B Virus.
•Hepatitis C Virus.
•Syphilis
•Positive units discarded.
Should Autologous Blood
be “made homologous”?

The American Medical

Association, AABB, discourage
the “crossover” of unused
autologous units to the general
blood supply.
 Pre-op. Autologous donation

Indications:
• Major Orthopedic surgeries:
(Hip & Knee replacement surgeries)
• Cardiovascular surgeries:
(Valve surgery & CP bypass surgery)
• Obstetric surgeries (hysterectomy, ovarian tumour etc.)
• Radical prostectomy, mastectomy,
• Gatro-surgery (Gall bladder, Gastectomy, splenectomy)
• Hepatic resection.
• Major spine surgery.
 Pre-op Autologous Donation

Contraindications:
1 Evidence of infection and risk of bacteremia.
2 Scheduled surgery to correct aortic stenosis.
3 Unstable angina.
4 Active seizure disorder.
5 Myocardial infarction or CV accidents.
6 Significant cardiac or pulmonary disease.
7 Cyanotic heart disease.
8 Uncontrolled hypertension.
9 Malignant diseases.
10 High grade left main CAD.
 Pre-op Autologous Donation

• Each blood centre or hospital that decides to conduct an

autologous blood collection program must have its own policies,
processes and procedures.

• Patient’s physician initiates the request for autologous services,

which then is approved by Transfusion Medicine physician after
physical evaluation.

• Patient advised oral supplemental iron.

 Pre-op Autologous Donation

• A sufficient number of units should be drawn to avoid

exposure to allogenic blood.

• Patients can give blood as frequently as every 3rd day

although once a week is more common.

• Optimal donation period begins 4-6 weeks before surgery.

• Difference between two collections >72 hours.

 Pre-op Autologous Donation
Handling and Storage
• ABO and Rh typing on labeled samples of patient.

• Units should have ‘green label’ with patient name & number &
marked ‘FOR AUTOLOGOUS USE ONLY’.

• Liquid storage is feasible for 6 weeks. For longer duration, the

unit have to be frozen.

• Special Autologous label may be used with numbering to

ensure that oldest units are issued first.
Autologous Sticker
 Acute Normovolemic
Hemodilution
Definition:

It is the removal of whole blood from a patient,

while restoring the circulating blood volume with an acellular
fluid shortly before an anticipated significant surgical blood
loss and transfused immediately after the surgery.

It is also known as ‘preoperative hemodilution’.

 Concept

• Hemodilution does not compromise the tissue oxygen delivery

as long as the hematocrit is maintained within acceptable limits.

Practical considerations:
• Minimal hemoglobin required for considering ANH is 12 gm/dl.

• Target hematocrit and vol of blood that can be collected

depends on pre-operative hematocrit and surgical
considerations
 Acute Normovolemic
Hemodilution
• Aseptic precautions should be used .

• Standard blood collection bags are used.

• When more than 1 unit has been collected they should be

numbered.

• The blood is then stored at room temp, and re-infused in

operating room after major blood loss within 8hrs.

• The unit collected 1st will be transfused last.

• Patient should be cautiously monitored.

 Acute Normovolemic
Hemodilution

• Blood units are re-infused in reverse order of collection.

• Theme behind:
behind Patient losses diluted blood during surgery
and replaced later with autologous blood.

• Withdrawal of whole blood and replacement of with crystalloid/

colloid solution decreases arterial O2 content but compensatory
hemo-dynamic mechanisms and existence of surplus O2
delivery capacity mechanism make ANH safe.
 Acute Normovolemic
Hemodilution
• Drop in red cell number lowers blood viscosity, decreasing
peripheral resistance and increasing cardiac output.

• Administrative costs are minimized and there is no inventory or

testing cost.

• This also eliminates the possibility of administrative or clerical

error.

• Usually employed for procedures with an anticipated blood loss

is one liter or more than 20% of blood volume.
 Acute Normovolemic
Hemodilution

• Decision about ANH should be based on surgical procedure,

preoperative blood volume and hematocrit, target
hemodilution hematocrit, physiologic variables.

• Careful monitoring of patient’s circulating volume and

perfusion status.
 Intra-operative Blood
Collection

Definition:
It is a technique of collecting and
retransfusing the blood lost from the patient
due to surgery with or without washing and
concentrating the RBC.
 Concept
• The blood lost during surgery can be recovered and used for re
administration for improving oxygen carriage.

• When properly planned and performed it can eliminate the need

for allogenic blood.

• The oxygen transport properties and survival of the RBC during

intraoperative blood collection are similar to RBCs in allogenic
blood transfusion.

• Like in other autologous transfusions blood collected is useful in

major cardiac, vascular and orthopedic surgeries.
 Practical considerations
• When a cell saver machine is used, process involves collection,
washing and concentrating RBC.

• Blood is collected by suction from bleeding parts or into the

collection reservoirs.

• Suction pressure should be < 150 mmHg to reduce hemolysis.

Deep suction reduces hemolysis.

• Topical application of pro coagulants like tropical collagen

renders blood unsuitable for collection.

• Micro aggregate filter(40 micrometer) is used to remove clots,

bone fragments, debris etc
 CONTD:

• Collected blood can be stored upto 4 hrs at room temperature

and upto 24 hrs at 1-6 0 c.

• Strict labeling procedure should be followed.

• Blood thus collected should be used only for autologous

transfusion.

• Each unit of washed blood contains 225 ml of saline

suspended RBC with a hematocrit of 50-60%.
 Postoperative Blood Collection
• Recovery of blood from surgical drain followed by re-
infusion with or without processing.

• Shed blood is collected into sterile canister and re-

infused through a micro-aggregate filter.

• Recovered blood is diluted, partially hemolysed and

de-fibrinated and may contain high concentrate of
cytokines.

• Upper limit on the volume(1400 ml) of unprocessed

blood can re-infused.
 Postoperative Blood Collection

• Transfusion should be within 6 hours of

initiating collection.

• Infusion of potentially harmful material in

recovered blood like free Hb, red cell stroma,
marrow fat , tissue debris, fibrin degradation
activated coagulation factors and
complement.
 Recent
Advances
 Three primary reasons driving the
quest for a substitute for Blood:

• Quantity
– Chronic shortages.
– Red Cross now relies on volunteer donations.

• Storage
– Blood is perishable.
– Long and short term storage is an expensive problem.

• Purity
– Compatible blood of the correct blood type is not always
available when needed.  
Types of Replacement Products

• Oxygen Carrying Solutions

– Hemoglobin Based Oxygen Carrying Solutions
(HBOCS)
– Perflourocarbons
• Other
– Antigen Camouflage
– Recombinant Plasma Proteins
– Transgenic Therapeutic Proteins
– Platelet Substitutes
 Oxygen Carrying Solutions

• Hemoglobin Based Oxygen Carrying

Solutions (HBOCS)
• Stroma free hemoglobin solutions

• Non-hemoglobin solutions
• perfluorocarbon emulsions
 Oxygen Carrying Solutions
Advantages include:

– Universally compatible
– No clerical errors
– Stored for long periods of time
– No prior planning
– Ready to use
– No waste
– No equipment
– Long shelf life
– No refrigeration
– Easily virally inactivated
– Available in the field for use in mass trauma situations
– Can be use by Jehovah's Witnesses
Perflourocarbon Oxygen Carriers
• Carry five times more oxygen.
• More effective off-loading of oxygen at the tissue level.
• Microdroplets that carry oxygen are 1/70th the size of the
red cells
– reach many areas of the body that human RBCs
cannot.
• The product is inert and can be fully sterilized
– removed from body over 4-12 hours via normal
respiration
• Stored at room temperature
• NO type and cross-matching prior to use.
 Perflourocarbon Oxygen Carriers
Indications:
“an all-purpose synthetic blood product”
– Surgery
– Trauma
– Angioplasty
– Open heart surgery
– Oxygenation of tumors during radiation or
chemotherapy
– Easily available:
• on the battlefield
• at the scene of accidents
• stored in emergency vehicles and emergency departments. 
• “Oxycyte” and “Oxygent”
Problems with Perflourocarbons

Side effects

– Phagocytosis of the PFCE particles causes flu-like

symptoms
• Fever
• muscle aches
• Nausea
• Vomiting
• Hepatosplenomegaly
• Decrease in blood platelet count
– PFCE particles cannot be metabolized

• 18-24 months to remove all of the particles

 Antigen Camouflage

• Camouflaging the surface of red blood cells

– Creates a universal blood type.
Polyethylene glycol (PEG)
– Biocompatible polymer forms a permanent covalent bond on
the surface of the cell.
– Coating effectively hides the antigenic molecules on the
surface of the red blood cells.
– Antigenically unrecognized by recipient's antibodies, and
therefore not destroyed.
 Antigen Camouflage
• Diseases requiring repeat blood transfusions
– often complicated by the development of antibodies to red
cell antigens.
– "allosensitization" can render these patients almost
impossible to transfuse.
– PEG-modified red cells
– do not trigger allosensitization.
– potentially useful in clinical situations where
allosensitization has already occurred.
Though antigenically "silent" these modified red cells:
– structurally normal.
– functionally normal.
– normal survival time. 
 Recombinant Plasma Proteins

• Can be made in unlimited quantities

• Specific deficient product replaced

• Free of blood-borne pathogens

• Factors VII, VIII and IV.

 Platelet Substitutes

• Approximately 18 million units of platelets are transfused each

year worldwide,

– 80% goes to patients who are thrombocytopenic as a result of

chemotherapy
 Platelet Substitutes
Synthocytes are microcapsules to which fibrinogen has been
chemically linked,
– act as a replacement for human blood platelets.
– selectively targeting the site of hemorrhage.

"Infusible Platelet Membranes"

– fragment the membrane of outdated platelets
– extract key hemostatic components of platelets
• Factor 3
• Glycoprotein 1b receptor
– reduces bleeding time in humans with aspirin ingestion
– controls mucosal bleeding in thrombocytomenic patients
refractory to platelet transfusions
– no antibodies to platelets were noted
– no significant toxicities
 Pharmacologic Therapy

• The necessity to reduce homologous blood use during

surgery has gained wide acceptance.

• Many attempts have been made to reduce the bleeding

tendency & blood requirement by pharmacological
interventions.
 APROTININ
• Aprotinin is a naturally occurring protease inhibitor.

• Aprotinin has been shown to reduce blood loss in cardiac and

liver surgery.

Side effects:
• Inadvertent re-exposure of a patient to aprotinin, with a high
risk of an anaphylactic reaction.

• Possible increase in thrombosis using a drug with anti-

fibrinolytic properties.
 DOSE

• The dose required for a significant effect on blood loss

appears to be high, with the majority of studies using a
loading dose of 2 million units over 20 min.followed by
0.5 million units/hour during surgery.
surgery
 Epsilon aminocaproic acid

• Antifibrinolytic agent.

• Bleeding is treated with a single dose of 5 gm intravenously.

 TRANEXAMIC ACID

• Tranexamic acid inhibits fibrinolysis by blocking the lysine

binding sites of plasminogen to fibrin.

• More recently it has also been shown to be effective in

reducing bleeding in cardiac surgery.
 DOSE

• Tranexamic acid has been used at 10-15 mg/kg.

• An infusion at the rate of 1 mg/kg/hour can be contunied.

• As tranexamic acid has a half-life of two hours there are

theoretical advantages to administering further doses
postoperatively.
 ERYTHROPOIETIN

• Human erythropoietin is a glycoprotein hormone that

regulates erythropoiesis.

• Hypoxic or haemorrhagic stress results in the secretion of

erythropoietin by the kidney.

• Erythropoietin is available as recombinant human

erythropoietin (epoietin a and b) and has been widely used in
the treatment of anaemia of chronic renal failure.
 The effect of erythropoietin

• The effect of erythropoietin in minimising allogeneic blood

exposure compared to placebo has been studied in patients
undergoing orthopaedic , cardiac or colon cancer surgery.

• All showed a significant reduction in allogeneic transfusion.

 Erythropoietin

• Erythropoietin use should be targeted to patients aged under

70 years who are scheduled for major blood losing surgery
and who have a presenting haemoglobin <13 g/dl.

• Erythropoietin can be used to prepare patients with objections

to allogeneic transfusion for surgery that involves major blood
loss.
 DOSE OF ERYTHROPOIETIN

The two dosing schedules most widely used are:

• 300 u/kg subcutaneously for 14 days beginning 10 days

preoperatively.
or
• 600 u/kg subcutaneously three times weekly and on day of
surgery.

Erythropoietin
• treatment has always been accompanied by oral or intravenous
iron therapy.
 Desmopressin acetate
• A synthetic analogue of arginine vasopressine hormone.

• It releases a variety of coagulation system mediators

from vascular endothelium.

• The overall effects is haemostasis.

Dose – 0.3 – 0.5 µg/Kg I V, intranasal , S.C.

• NO ONE SHOULD DIE WITHOUT BLOOD.

• NO ONE SHOULD DIE WITHOUT BLOOD

DONATION.
Thank you for
your patient
hearing !