Red cell transfusion EBM 2

Red Cell Transfusion Guidelines and EBM: 

G A Damanhouri FRCPA ,FRCPI, FRCPath Department of Hematology KAUH,Jeddah , KSA gdamanhouri@gmail.com www.gdamanhouri.kau.edu.sa Red Cell Transfusion Guidelines and EBM

RBC transfusion: 

RBC transfusion

Questions: 

Questions

Red Cell Transfusion: 

Red Cell Transfusion

History: 

History Ibn al- Nafis He was born in 1213 in Damascus. He attended the Medical College Hospital ( Bimaristan Al- Noori ) in Damascus. died in 1288, he donated his house, library and clinic to the Mansuriya Hospital. was an Arab physician who is mostly famous for being the first to describe the pulmonary circulation of the blood . Ibn al- Nafis

History: 

History

History: 

History 1840 At St. George's School in London, Samuel Armstrong Lane, aided by consultant Dr. Blundell, performs the first successful whole blood transfusion to treat hemophilia. 1867 English surgeon Joseph Lister uses antiseptics to control infection during transfusions. 1873-1880 US physicians transfuse milk (from cows, goats, and humans). 1884 Saline infusion replaces milk as a “blood substitute” due to the increased frequency of adverse reactions to milk. 1900 Karl Landsteiner,

Past: 

Past

Present: 

Present

Present: 

Present

Future: 

Future No Blood Transfusion Alternatives

Blood group systems: 

Blood group systems * ABO 1901 * MN 1927 * LW 1930 * Lewis 1946 * Rh 1939 * LU 1945 * KeLL 1946 * Duffy 1950 * Kidd 1951 * Diego 1955 * Xg 1962 * Yt 1956 * Do 1965 * Colton 1967

Continues Blood group system: 

Continues Blood group system * Scianna (Sc) * Radin (Rd) * Cromer (Cr) * Gergich (Ge) * Sc * Chido,Rogers * Bg * Hh * Indian * Kx * Secretor (Sc) * P1 * Ok * LW

Platelet Specific Antigens Antigens Phenotypic %: 

Platelet Specific Antigens Antigens Phenotypic % HPA-1a 98 HPA -1b 27 HPA -4a 99 HPA -4b < 1 HPA 6(b) < 1 HPA 8(b) < 1 HPA 7(b) < I

HLA Complex: 

HLA Complex

Blood Transfusion = Organ Transplantation: 

Blood Transfusion = Organ Transplantation

Adverse Effects Of Transfusion Immediate Immunological: 

Adverse Effects Of Transfusion Immediate Immunological * Hemolysis * Febrile non hemolytic reaction. * Anaphylaxis * Urticaria *Non-cardiac pulmonary edema . Image Search Yahoo! Close Yahoo! frame

Continues Adverse Effects of Transfusion Immediate Non-Immunological Etiology : 

Continues Adverse Effects of Transfusion Immediate Non-Immunological Etiology * Marked fever & Shock * Congestive Heart Failure * Haemolysis Bacterial contamination Volume Overload Physical Destruction e.g. Freezing or Overheating

Continues Adverse Effects of Transfusion Delayed Effects Immunological Etiology: 

Continues Adverse Effects of Transfusion Delayed Effects Immunological Etiology * Haemolysis * Graft Vs Host disease * Post-Transfusion Purpura * Alloimmunization Anamnestic Antibody Reaction Engraftment of Functional Transfused Lymphocytes Anti platelet Abs Exposure to Antigens of Donor Origins

Continues Adverse Effects of Transfusions Delayed Effects Non-Immunological Etiology: 

Continues Adverse Effects of Transfusions Delayed Effects Non-Immunological Etiology Iron Overload Hepatitis AIDS Protozoa Infection Multiple Transfusion HVB, HCV, and Non-A, Non-B, and Non-C HIV -I / HIV-2 Malaria, Babesia Trypanosomes

IS BLOOD TRANSFUSION A SAFE PROCEDURE ??: 

IS BLOOD TRANSFUSION A SAFE PROCEDURE ??

Slide 25: 

In developing world, unneeded blood transfusions speed the spread of AIDS By Ilan Greenberg Published: March 15, 2007 In developing world, unneeded blood transfusions speed the spread of AIDS

Slide 26: 

Doctors order unnecessary blood transfusions for cancer patients to make them eligible for research studies Chief medical officer warns that many blood transfusions are unnecessary BMJ 2004 329-308

Slide 27: 

I thing we are in trouble Ok .. So we are in need for a road map What we should do ?

Slide 28: 

EBM is integration of best research evidence with clinical expertise and patient values. Evidence-based medicine relies on; Clinical research Accuracy of diagnostic tests Efficacy and safety of therapeutic & Preventive interventions.

Slide 29: 

It means that physicians should be able to manage each patient on the basis of the best available research evidence, and they should gain the necessary skills to make independent assessments of that evidence rather than depend on opinions offered by experts

Slide 30: 

Collecting Identification Transportation Preparation Analysis Reporting Interpretation Interpretation Action Physician’s Brain Requesting The Diagnostic Process

Slide 31: 

Law Politics Perception Practice Evidence Science Decisions

Slide 33: 

. Carson JL et al. (1998). Perioperative transfusion and postoperative mortality. Journal of the American Medical Association; 279:199-205 .

Slide 34: 

Wahr JA (1998). Myocardial ischaemia in anaemic patients. British Journal of Anaesthesia ; 81: Suppl 1:10-15.

Slide 35: 

Lieberman JA et al. (2006). Critical oxygen delivery in conscious humans is less than 7.3 ml. O2.kg.min. Anesthesiology; 92:407-13.

Slide 36: 

Hunt TK, Goodson WH (1989). Uncomplicated anaemia does not influence wound healing In: The role of hemodilution in optimal patient care. Eds. Tuma RF, White JV, Mesmer K: 43-50.

Slide 37: 

Jensen LS, Kissmyer-Nielson P, Wolff B and Qvist N (1996). Randomised comparison of leucocyte-depleted versus buffy coat poor blood transfusion and complications aftercolorectal surgery. Lancet; 348:841-45.

Slide 38: 

Lacroix J, Hebert PC, Hutchinson JS Hume A et al. (2007) Transfusion strategies for patients in paediatric intensive care units New England Journal of Medicine; 356:1609-1619.

Slide 42: 

< 30% loss of blood volume (< 1500ml in an adult): transfuse crystalloids. Red cell transfusion is unlikely to be necessary. 30-40% loss of blood volume (1500-2000ml in an adult): rapid volume replacement is required with crystalloids. Red cell transfusion will probably be required to maintain recommended Hb levels. >40% loss of blood volume (>2000ml in an adult): rapid volume replacement including red cell transfusion is required.

Slide 43: 

Assuming normovolaemia has been maintained, the Hb can be used to guide the use of red cell transfusion. Hb <7g/dl. Hb <8g/dl in a patient with known cardiovascular disease, or those with significant risk factors for cardiovascular disease (e.g. elderly patients, and those with hypertension, diabetes mellitus, peripheral vascular disease).

Slide 44: 

Transfuse to maintain the Hb >7g/dl, and >8g/dl in elderly patients and those with known cardiovascular disease

Slide 45: 

There is no evidence-base to guide practice. Most hospitals use a transfusion threshold of a Hb of 8 or 9g/dl

Slide 46: 

There is little evidence-base to guide practice. Suggest transfuse to maintain the Hb >10g/dl.

Slide 47: 

Transfuse to maintain the haemoglobin concentration to prevent symptoms of anaemia. Many patients with chronic anaemia may be asymptomatic with a Hb >8g/dl.

Slide 48: 

Is there a red blood cell transfusion trigger ?? The "transfusion trigger" or minimal hematocrit or hemoglobin level at which adult patients require transfusions has been the subject of clinical investigation and controversy.

Slide 49: 

Red cell transfusion is rarely needed if the hemoglobin concentration is greater than 10g/dL, and almost always needed when the level is less than 6g/dL.

Slide 50: 

• A haemoglobin concentration of 8-10 g.dl is a safe level even for those patients with significant cardiorespiratory disease. Transfusion will become essential when the haemoglobin concentration decreases to 5 g.dl • Symptomatic patients should be transfused

Slide 51: 

Evaluating the risk: benefit ratio for transfusion-taking into account the patient's lifestyle, other medical conditions, and prognosis. What about changing the term Blood Transfusion to Blood Transplantation???

Slide 52: 

“We’re looking for somebody who’s capable of seeing the big picture”

Slide 53: 

If you start with the problem you may find a way out. If you start with the solution you are likely to be locked out. BACK TO BASICS!

Slide 54: 

I think I know now why Dr Hindawi ordered the 10 units of whole blood