INTRODUCTION:
 Blood transfusion is the process of transferring
blood or blood-based products from one person into
the circulatory system of another.
 It can be life-saving in some situations, such as
massive blood loss due to trauma , or can be used to
replace blood lost during surgery.
 Blood transfusions may also be used to treat a
severe anemia or thrombocytopenia caused by a
blood disease.
 People suffering from hemophilia or sickle-cell
disease may require frequent B.T
 Early transfusions used whole blood, but modern
medical practice is to use only components of the
blood.
History:
 The first historical attempt at blood transfusion
was described in 15th-century.
 The first fully-documented human blood
transfusion was administered by Dr. Jean- Denis,
eminent physician to King Louis XIV of France, on
June 15, 1667. He transfused the blood of a sheep
into a 15-year old boy, who recovered
 In 1818, Dr. James Blundell, a British obstetrician,
performed the first successful blood transfusion of
human blood, for the treatment of postpartum
hemorrhage.
 Many patients had died and it was not until 1901,
when the Austrian( Karl) discovered human blood
groups, that blood transfusions became safer
&awarded the Nobel Prize in Physiology or
Medicine
World War II syringe for direct interhuman
blood transfusion
 While the first transfusions had to be made
directly from donor to receiver before coagulation,
in the 1910s it was discovered that by adding
anticoagulant and refrigerating the blood it was
possible to store it for some days, thus opening the
way for blood bank.
 The first non-direct transfusion was performed on
March 27, 1914 by the Belgian doctor Albert
Hustin, who used sodium citrate as an
anticoagulant .
 Transfusion of blood products is one of the most
common interventions in the hospital setting.
 The number of blood components trans-fused in
the United States was approximately 29 million in
2004 & This equates to nearly 80,000 units of
blood components transfused every day.
Processing of blood prior to
transfusion:
The Donated blood is usually subjected to processing after it
is collected
 Component separation.
 Leukoreduction, also known as Leukodepletion is the
removal of white blood cell from the blood product by
filtration.
 Irradiation.
 Viral screening
 Although blood transfusion saves lives and reduces
morbidities in many clinical diseases and
conditions, it is associated with certain risks.
 The most serious risks of blood transfusion are
transfusion reaction which is include (immunerelated reactions ,non immune reactions and
infections).
The transfusion reaction:
There are several types of reactions and some are
more severe than others. Some reactions may
happen as soon as the transfusion is started, while
some take several days or even longer to develop.
Immune-related reactions:
 occur when the immune system attacks
components of the blood being transfused or
when the blood causes an allergic reaction.
 These reactions may be mild or severe. Most mild
reactions are not life-threatening when treated
quickly.
1-Nonhemolytic fever reactions or
febrile reaction:
It is sudden fever during or within 24 hours of the
transfusion may be associated with Headache,
nausea, chills, or a general feeling of discomfort.
 These reactions are a response by the body to
white blood cells in the donated blood.
 They are more common in people who have had
transfusions before, and in women who have had
several pregnancies.
 The Acetaminophen (Tylenol) may help these
symptoms.
 Patients who have had febrile reactions or who are
at risk for them are usually given blood products
that are leukoreduced (This means that the white
blood cells have been removed by filters or other
means).
2-The allergic reaction:
 This is the most common type of reaction&It
occurs during the transfusion because of the
body's reaction to plasma proteins in the donated
blood.
 Usually the only symptoms are hives and itching,
which can be treated with antihistamines such as
diphenhydramine.
In rare cases these reactions can be more serious
cause:
 Anxiety
 Chest and/or back pain
 Trouble breathing
 Fever, chills, flushing, and clammy skin
 A high pulse or low blood pressure &nausea
Which can be life-threatening(anaphylactic shock)
In this case we have to stop the transfusion
immediately at the first signs of an allergic
reaction. determines how mild or severe the
reaction is, what treatments are needed, and
if the transfusion can safely be restarted.
3-Transfusion-related acute lung
injury (TRALI):
 This is a very serious transfusion reaction, which
happens in about 1 out of every 5,000 transfusions.
 It can happen with any type of transfusion, but
those that contain more plasma, such as FFP or
platelets
 It often starts within 1 to 2 hours of the
transfusion, but can happen anytime up to 6 hours
after the transfusion.
 The main symptom a patient will feel is trouble
breathing
 Doctors now believe that there are several factors
involved in this illness such as(recent surgery,
trauma, cancer treatment, transfusion, or have an
active infection).
 Most of the time TRALI goes away within 2 or 3
days if the breathing and blood pressure are
supported, but even with support it can cause
death in 5% to 10% of cases.
 It is more likely to be fatal if the patient was
already very ill before the transfusion.
 Most often a patient will need oxygen, fluids, and
sometimes support with a breathing machine.
 If a patient who has had TRALI needs blood, we
need to prevent future problems by "washing" the
red cells in a dilute salt water solution to remove
most of the plasma while saving the red blood
cells.
4- Acute immune hemolytic
reaction:
 is the most serious type of transfusion reaction,
but it is very rare & It happens when donor and
patient blood types do not match.
 The patient's antibodies attack the transfused red
blood cells, causing them to break open
(hemolyze) and release harmful substances into
the bloodstream.
 Patients may have chills, fever, chest and
lower back pain, and nausea.
 The kidneys may be severely damaged, and
dialysis may be needed.
 It can be cause death if the transfusion is
not stopped as soon as the reaction starts
5-Delayed hemolytic reaction:
 This type of reaction happens when the body
slowly attacks antigens (other than ABO antigens)
on the transfused blood cells.
 The blood cells break down days or weeks after
transfusion& usually no symptoms, but the
transfused red blood cells are destroyed and the
patient's red blood cell count falls.
 In rare cases the kidneys may be affected,
requiring treatment.
 People don't usually have these types of reactions
unless they have had several transfusions in the
past.
 People who have this type of reaction need special
blood testing before any more blood can be
transfused.
6-Graft-versus-host disease
(GVHD):
 occurs when white blood cells in transfused blood
attack the tissues of a transfusion recipient who
has a severely weakened immune system.
 It is more likely to happen if the person getting the
blood is a relative or has a similar tissue type to the
donor
 The recipient's immune system doesn't recognize
the white blood cells in the transfused blood as
foreign& This allows them to survive and attack
the recipient's body tissues.
 Within a month of the transfusion, the patient
may have fever, liver problems, rash, and diarrhea
 To prevent white blood cells from causing
GVHD,the donated blood can be treated with
radiation before transfusion.
 Radiation stops white blood cells from working
but does not affect red blood cells.
Nonimmune reactions:
1-Fluid overload:
 it is a common type of nonimmune reaction & it
occur when Pt receive too much fluid through
transfusions, especially if he has not experienced
blood loss before the transfusion.
 It may require treatment with (diuretics)
medications to rid the body of the excess fluid.
2- Acquired hemochromatosis:
 Very rarely, a person can develop iron overload
after having many repeated blood transfusions.
 People with a blood disorder like thlassemia which
requires multiple transfusions, are at risk of iron
overload and because of this they are usually on
chelating agent to remove the extra iron from there
body.
Infections:
 Blood transfusions can transmit infections caused
by bacteria, viruses, and parasites.
 The chance of an infection being transmitted is
very rare, but the exact risk for each type of
infection varies.
Bacterial contamination:
 Rarely, blood gets contaminated with tiny amounts
of skin bacteria during donation.
 Platelets are the most likely blood component to
have this problem. Because platelets must be
stored at room temperature, these bacteria can
grow rapidly
 It is affects about 1 in 1000 to 3000 units of
platelets.
 Patients receiving these platelets may develop
serious illness within minutes or hours after the
transfusion is started
 In 2004, blood banks started testing platelets
before they are given and throwing out affected
units.
Hepatitis B and C:
 Hepatitis is the most common disease transmitted
by blood transfusions.
 According to the American Red Cross, about 1
blood transfusion in 205,000 transmits a hepatitis
B infection, and 1 blood transfusion in about 2
million transmits hepatitis C.
 Several steps are routinely taken to reduce the risk
of hepatitis from blood transfusion
 People who are getting ready to donate blood are
asked questions about hepatitis risk factors and
symptoms of hepatitis & the Donated blood is
also tested to find HBV,HCV and liver problems
that might point to other types of hepatitis.
Human immunodeficiency virus
(HIV):
 Testing each unit of donated blood for HIV began in
1985, and tests for HIV are now used on all donated
blood.
 With improved testing for HIV, the number of
transfusion-related AIDS cases continues to drop.
 The risk of HIV transmission from a
transfusion now is about one in 2,135,000 &
In addition to testing, the risk is reduced by
asking donors questions about HIV risk
factors and symptoms.
Other infections tested:
 In addition to the tests noted above, all blood for
transfusion is tested for syphilis, as well as T-cell lymph
tropic virus types I and II (HTLV-I/II) linked to human Tcell leukemia/lymphoma, (CMV), (EBV), TT virus (TTV),
human herpes virus type 6 (HHV-6), SEN virus (SEN-V),
and human parvovirus (HPV-B19).
 Since 2003, donated blood has been tested for the West
Nile virus too
Other possible infections:
Diseases caused by certain bacteria, viruses, and
parasites, such as Chagas disease, malaria, Lyme
disease, and others can also be spread by blood
product transfusions But because potential donors
are screened with questions about their health
status and travel, such cases are very rare.
Classification of transfusion-related adverse events
Time Mechanis
of
m
Occu
rrenc
e
Infectious
Reaction
Acute Immune
mediated
Nonimmu
ne
mediated
Noninfectious Reaction
Acute hemolytic transfusion reaction
Transfusion-related acute lung injury
Febrile nonhemolytic transfusion reaction
Urticarial reaction
Anaphylactic
Bacterial
contaminatio
n
Nonimmune hemolysis (e.g.
hemoglobinuria)
Circulatory overload
Metabolic (e.g. hyperkalemia)
Embolic
Delayed
Immune
mediated
Nonimmun
e mediated
Delayed hemolytic transfusion
reaction
Transfusion associated graftversus-host disease
Post transfusion purpura
Transfusion
Transmitted
infections
(viral, bacterial
and parasitic)
Hemochromatosis (iron overload)
Neonatal transfusion:
 hospitals are taking additional precaution to avoid
infection and prefer to use specially tested
pediatric blood units that are guaranteed negative
forCMV.
 There are pecific requirements place additional
restrictions on blood donors who can donate for
neonatal use.
 Neonatal transfusions are usually top-up
transfusions, exchange transfusions, partial
exchange transfusions.
 Top-up transfusions are for investigational losses
and correction of mild degrees of anemia5-15
ml/kg ,removal of bilirubin, removal of antibodies
and replacement of red cells
 Ideally plasma-reduced red cells that are not older
than 5 days are use.
Transfusion and Patient Outcomes
 A large number of recent (within the last 7-10
years) studies have shown a profound association
between transfusion and adverse outcomes.
 Today there is mounting evidence that patients
who are transfused do worse than patients who are
not
 In orthopedic surgery, patients who have received
allogeneic (banked) blood have a 1.5- to 3.5-fold
increased risk for preoperative major infection
which includes wound infection, pneumonia,
sepsis, and urinary tract infection which lead to
prolonged hospital stay.
 In open heart surgery, those who receive units of
blood have a longer stay in the hospital, have more
chance for pneumonia, more infections , more
respiratory complications, more kidney and heart
problem , more strokes and ultimately at least
twice the death rate than those not transfused.
 Patients who are transfused have more heart
arrhythmias (atrial fibrillation), heart failure,
inability to wean from the bypass machine, and
other additional adverse outcomes.
 Also, several studies have demonstrated higher
cancer recurrence rates in transfused versus no
transfused patients with cancer due to
Transfusion-related immunomodulation (TRIM)
but still there is controversy.
Blood Management Strategies
In response to these issues, health care providers
and hospitals are developing multiprofessional
strategies to improve blood utilization, improve
patient outcomes, and reduce costs.
key principles for developing effective
blood management
 Early identification and intervention for patients
at high risk for transfusions
 Utilization of current scientific evidence and the
promotion of clinical best practices
 Coordination of all members of the health care
team
 Patient advocacy and patient safety
 Stewardship of scarce and expensive hospital
resources
Preoperative Preparation and Planning:
 Preoperative preparation and planning are
essential elements for the safe and optimal
management of surgical patients.
 Formal protocols for preoperative testing of
hemoglobin level for major blood loss surgeries
and coagulation status testing in certain patient
populations are important for this early
identification and intervention.
 discontinuation of drugs such as aspirin, warfarin,
and clopidogrel, as well as certain herbal
supplements that increase bleeding including
garlic, ginkgo, and ginseng.
 Anemia management protocols are essential to
blood management programs because they
selectively use iron and erythropoiesis-stimulating
agents to eliminate the need for allogeneic blood
during moderate-to-high blood loss surgeries.
Nonpharmacologic Strategies:
 One such strategy is to minimize the impact of
diagnostic phlebotomy on the development of
iatrogenic anemia, especially in critically ill
patients.
 discontinuation of invasive lines (e.g., arterial
catheters, central venous catheters) .
 Use of small-volume sampling tubes (e.g.,
pediatric sampling tubes)
 Point-of-care bedside analytic techniques (e.g.,
blood glucose analyzers, arterial blood gas
analyzers) that require only small volumes of
blood can be used to accomplish the same goal.
 Intraoperative blood recovery (i.e., cell salvage
methods) with subsequent reinfusion of shed
blood into a patient that has experienced
significant surgical bleeding.
 Minimally invasive surgical techniques which
include laparoscopic, endoscopic, robotic, and
transcatheter techniques, low central venous
pressure anesthesia as well as use of advanced
surgical instrumentation (e.g., ultrasonic scalpel,
argon bean coagulator).
All these of measurement is apart the
principles of bloodless surgery
Iron Therapy:
 Inadequate iron stores will eventually result in
iron-deficient anemia.
 iron replacement therapy is warranted to reverse
the anemia and minimize the use of red blood cell
transfusions & it involves enteral administration
of ferrous sulfate, gluconate, fumarate, or iron
polysaccharide in ambulatory patients with irondeficient anemia.
 parenteral iron replacement therapy with
iron sucrose, ferric gluconate, or iron
dextran is often required because of
gastrointestinal adverse effects associated
with the enteral products or compromised
enteral bioavailability in critically ill
patients.
Erythropoiesis-Stimulating Agents:
 Among the pharmacologic strategies to minimize
allogeneic blood transfusions.
 Two such agents are available in the United States,
namely, epoetin alfa and darbepoetin alfa.
the FDA has recently recommended to use the
lowest dose possible of (ESA)to gradually increase
the hemoglobin concentration and to target
hemoglobin concentrations that do not exceed 12
g/dl in the patients with chronic renal failure,
patients with cancer who are receiving
chemotherapy, and surgical candidates
One of the biggest factors that could limit the
use of epoetin alfa and darbepoetin alfa in
all patient subsets relates to their
pharmacoeconomics
Hemostatic Blood Products and Drugs:
 a number of pharmacologic agents have been used
as adjunctive therapies to control bleeding. One of
the more controversial agents over the last few
years is the off-label use of rFVIIa.
 Adverse events (i.e., death, thromboembolic
events, multiple organ failure, and acute
respiratory distress syndrome +it COST in trauma
25,000
 Other pharmacologic agents that have been
investigated for their adjunctive role in reducing
blood loss include desmopressin and the
antifibrinolytics, aprotinin, tranexamic acid, and
epsilon-aminocaproic acid.
Blood substitutes:
 also called artificial blood or blood-surrogates)
are used to fill fluid volume and/or carry oxygen
and other blood gases in the CVS.
 The preferred and more accurate are volume
expanders for inert products, and oxygen
therapeutics for oxygen-carrying products
Examples of these two "blood substitute"
categories:
 Volume expanders:
These may be crystalloid-based (RL,NS, D5W)or
colloid-based (Hespan, haemaccel).
 Oxygen therapeutics:
it is divided two categories based on transport
mechanism perflorocarbon based, and
hemoglobin based.
Artificial Oxygen Carriers:
 The quest for artificial oxygen carrier solutions as
alternatives to allogeneic B.T has spanned decades.
 these products have focused primarily on the
perioperative setting, sustaining regional perfusion
(e.g., stroke, myocardial infarction), and acute
hemorrhagic shock.
Artificial Oxygen Carriers
Hemoglobin based
Perfluorocarbon based
 Hemopure.
 Oxygent
 Oxyglobin.
 Oxycyte.
 PolyHeme.
 Hemospan
 Dextran-Hemoglobin
 Although most of these products have been
approved for use in the United States or Europe,
clinical trials are investigating the safety and
efficacy of these agents.
 Oxyglobin solution is the first and only oxygen
therapeutic to be both US FDA and European
Commission approved for veterinary use
Promising techniques:
 Stem cell.
 dendrimers .
 Biodegradable Micelles.
 Placental umbilical cord blood.
At the moment, the complex three step method
of producing the cells would make a unit of
these red blood cells too expensive.
Autologous Predonation:
 Typically, patients will donate 1–3 units of packed
red blood cells over a 3–4-week period before their
elective surgery.
 Risks associated with preoperative autologous
donation include transfusion-associated
circulatory overload and the potential for
misidentification during the transfusion process.
 These two risks are due to lower hemoglobin levels
in preoperative autologous donation cases &
moving them closer to a transfusion trigger.
 the use of autologous predonated blood can cause
an iatrogenic anemia & There is also the potential
for waste if the unit collected is not needed, which
on average occurs in more than half of
preoperative autologous donation cases.
Conclusion:
 In many cases, transfusions are the end result of
the actions or interactions of health care providers
and hospitals to manage a series of events in
complex patients.
 Alternatively stated, the goal of blood
management is to ensure that each and every
blood product that is transfused is appropriate,
and that blood-related resources are used
effectively.
 The corner stones of blood management programs
are the implementation of evidence-based
transfusion guidelines to reduce variability in
transfusion practice, the employment of
multidisciplinary teams to study, implement and
monitor local blood management strategies.
THANK YOU
Dr. Amani AL-Haddad
Pediatric surgery