TRANSFUSION IN THE EMERGENCY

DEPARTMENT

DR. PRANNOY GEORGE,

DEPARTMENT OF EMERGENCY MEDICINE AND CRITICAL
CARE,
AIMS, KOCHI
 A BRIEF HISTORY OF BLOOD TRANSFUSION THROUGH THE
YEARS
 1628 English physician William Harvey discovers the circulation of blood. Shortly afterward, the earliest known blood transfusion is attempted.
 1665 The first recorded successful blood transfusion occurs in England: Physician Richard Lower keeps dogs alive by transfusion of blood from other dogs.
 1818 James Blundell performs the first successful blood transfusion of human blood to treat postpartum hemorrhage.
 1840 The first whole blood transfusion to treat hemophilia is successfully completed.
 1900 Karl Landsteiner discovers the first three human blood groups, A, B and O.
 1902 Landsteiner’s colleagues, Alfred Decastello and Adriano Sturli, add a fourth blood type, AB.
 1907 Blood typing and cross matching between donors and patients is attempted to improve the safety of transfusions. The universality of the O blood group is identified.
 1914 Adolf Hustin discovers that sodium citrate can anticoagulate blood for transfusion, allowing it to be stored and later transfused safely to patients on the battlefield.
 1932 The first blood bank is established at Leningrad hospital.
 1939-1940 The Rh blood group is discovered and recognized as the cause behind most transfusion reactions.
 1940 The US government establishes a nationwide blood collection program.
 1950 Plastic bags allowing for a safer and easier collection system replace breakable glass bottles used for blood collection and storage.
 1961 Platelet concentrates are recognized to reduce mortality from hemorrhaging in cancer patients.
 1970 Blood banks move towards an all-volunteer donor base.
 1972 The process of apheresis is discovered, allowing the extraction of one component of blood, returning the rest to the donor.
 1983 Stanford Blood Center is the first blood center to screen for AIDS contaminated blood, using a surrogate test (T-lymphocyte phenotyping) two years before the AIDS virus
antibody test is developed.
 1985 The first HIV blood-screening test is licensed and implemented by blood banks.
 1987 Stanford Blood Center is the first in the country to screen donors for Human T-Lymphotropic Virus Type I (HTLV-I), a virus believed to cause a form of adult leukemia.
 1990 A specific test to identify Hepatitis C is introduced.
 2002 West Nile Virus is identified as transfusion-transmissible.
EVOLUTION OF BLOOD TRANSFUSION
INTRODUCTION

 Blood product transfusion occurs in a significant percentage of intensive care unit (ICU)
patients (20–50%).
 The emergency department (ED) is the entry point for the majority of patients in the ICU.
Excluding massive transfusion protocols in the setting of major trauma, there is little
evidence describing transfusion in the ED setting or its potential impact on outcome.
 One unit of packed red cells transfused will increase the hemoglobin by one gram/dl and
Hematocrit by three percent.
 Blood product transfusion is associated with well-documented risks such as acute
respiratory distress syndrome (ARDS), transfusion-related acute lung injury (TRALI), and
transfusion-associated circulatory overload (TACO), etc.
 “TRANSFUSION TRIGGER”

 It is the hemoglobin or hematocrit level below with a blood transfusion was to be given.
 Most available trials compared outcomes in patients transfused at Hb thresholds between 7
and 10 g/dL.
 The current paradigm of the transfusion trigger of Hb 7 g/dL comes from the TRICC trial
BLOOD PRODUCTS

 Whole blood- Stored whole blood, Fresh whole blood

 Components-

1. Cellular Components: Red cell concentrates, platelet concentrates, granulocyte

concentrate
2. Plasma Components: FFP, cryoprecipitate, cryo-poor plasma, stored plasma
3. Plasma Derivatives: Albumin, immunoglobulin, coagulation factors
CONDITIONS IN WHICH WE TRANSFUSE BLOOD AND BLOOD
PRODUCTS IN THE ED

 Ongoing large volume blood loss

 Severe anemia with serious cardiac issues
 DIC
 Bleeding in hemophilia and other disorders
 Hypo-proteinemia
CONTROVERSIES

 Transfusion in Sepsis
 Transfusion in the Critically ill
 Transfusion in GI bleed
 Transfusion in patients with Acute MI
 Transfusion in Pediatric population
 Transfusion in the Cardiac surgery patients
 Transfusion in trauma
TRANSFUSION IN SEPSIS

 Blood transfusions are frequently given to patients with septic shock.

 Largest trial done – TRISS trial (Scandinavian Critical Care Trials Group)
 Some of these transfusions are given to patients who are bleeding, but many non-bleeding
patients also undergo transfusion.
 The recommendations of the Surviving Sepsis Campaign regarding blood transfusion in
patients with septic shock are complex and include a recommendation for transfusion to
maintain a hematocrit of more than 30% in the presence of hypoperfusion in the first 6
hours.
 After that, the transfusion threshold should be a hemoglobin level of less than 7 g per
deciliter, aiming at levels between 7 g and 9 g per deciliter in patients who do not have
myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic coronary artery
disease.
 TRISS TRIAL

 In this multicenter, parallel-group trial, patients were randomly assigned who had septic
shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leuko-
reduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold)
or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The
primary outcome measure was death by 90 days after randomization.
RESULTS AND CONCLUSIONS FROM THE STUDY
 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223
of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95%
confidence interval, 0.78 to 1.09; P=0.44).

 The results were similar in analyses adjusted for risk factors at baseline and in analyses of
the per-protocol populations. The numbers of patients who had ischemic events, who had
severe adverse reactions, and who required life support were similar in the two
intervention groups.

 Conclusion: Among patients with septic shock, mortality at 90 days and rates of ischemic
events and use of life support were similar among those assigned to blood transfusion at a
higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold;
the latter group received fewer transfusions.
TRANSFUSION IN CRITICALLY ILL PATIENTS

 Red cell transfusions are a cornerstone of critical care practice.

 Anemia is not well-tolerated by critically ill patients.
 Red-cell transfusions were used to augment the delivery of oxygen, in the hope of avoiding
the deleterious effects of oxygen debt.
 This view prompted the routine use of transfusion in patients with hemoglobin
concentrations that were often more than 10.0 g per deciliter in studies evaluating
resuscitation protocols.
 There are divergent views on the risks of anemia and the benefits of transfusion.
THE CRIT STUDY

 Incidence of anemia and red blood cell (RBC) transfusion practice in critically ill patients and to
examine the relationship of anemia and RBC transfusion to clinical outcomes.
 Conclusion: Anemia is common in the critically ill and results in a large number of RBC transfusions.
Transfusion practice has changed little during the past decade. The number of RBC units transfused
is an independent predictor of worse clinical outcome.
 TRICC TRIAL

 Trial was conducted to determine whether a restrictive strategy of red-cell transfusion and
a liberal strategy produced equivalent results in critically ill patients, we compared the
rates of death from all causes at 30 days and the severity of organ dysfunction.
RESULTS AND CONCLUSIONS FROM TRICC TRIAL

 Overall 30-day mortality remained similar in both groups (18.7% vs. 23.3%, p=0.11),
however mortality was significantly lower with the restrictive strategy among patients who
were less acutely ill (APACHE II <20) – 8.7% vs 16.1%.
 and among patients who were less than 55 years of age (5.7 percent and 13.0 percent,
respectively; P=0.02), but not among patients with clinically significant cardiac disease
(20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during
hospitalization was significantly lower in the restrictive-strategy group (22.2 percent vs.
28.1 percent, P=0.05).
 A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior
to a liberal transfusion strategy in critically ill patients, with the possible exception of
patients with acute myocardial infarction and unstable angina.
TRANSFUSION IN GI BLEED

 Acute upper GI bleed a common emergency condition associated with high morbidity and
mortality.
 It is a frequent indication for red-cell transfusion, because acute blood loss can decrease
tissue perfusion and the delivery of oxygen to tissues.
 Transfusion may be lifesaving in patients with massive exsanguinating bleeding.
 In most cases hemorrhage is not so severe, and in such circumstances the safest and most
effective transfusion strategy is controversial.
 Hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal
bleeding is controversial.
EVIDENCE

 Study published in NEJM compared the efficacy and safety of a restrictive transfusion
strategy with those of a liberal transfusion strategy in acute upper GI bleed
RESULTS AND CONCLUSION FROM THE STUDY

 A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal
strategy (14%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the
restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with
restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10%
of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy
group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of
survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of
patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was
significantly higher in the subgroup of patients with cirrhosis and Child–Pugh class A or B disease (hazard ratio,
0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (hazard ratio, 1.04;
95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients
assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.
 As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in
patients with acute upper gastrointestinal bleeding.
TRANSFUSION IN PATIENTS WITH ACUTE MI

 Perioperative anemia is one of the commonest status for patients with acute myocardial
infarction (MI) or other acute cardiovascular events, which always threats patient prognosis
and is always associated with increased risk of all-cause mortality
 Blood transfusion is one of the most efficient ways to help MI patients improve myocardial
oxygen delivery when red blood cells are transfused which may augment hemoglobin
levels.
 Despite its recognized advantages of blood transfusion for MI, it may also increase some
related risks, such as increased risk of infection, allergic reaction, high fever, volume
overload and hemolytic reaction
 In patients with MI, blood transfusion treatment is associated with patient short-term and
long-term all-cause mortality.
TRANSFUSION IN PEDIATRICS

 Transfusion is performed much less often in older infants and children. The most commonly transfused
groups are children on paediatric intensive care units (PICUs), those undergoing cardiac surgery,
transfusion-dependent children with inherited conditions such as thalassaemia major, and those following
intensive chemotherapy for haematological malignancy or cancer. 
 Red cells are transfused at up to 5 mL/kg/h (unless there is active major bleeding) and the transfusion
should be completed within 4 hours
 Apheresis platelets should be used for all children <16 years old to reduce donor exposure. The typical
dose for children weighing less than 15 kg is 10–20 mL/kg. Children above 15 kg may receive a single
apheresis donation (approximately 300 mL). The recommended rate of administration is 10–20 mL/kg/h. 
 FFP should not be administered prophylactically in non-bleeding patients or to ‘correct’ minor
abnormalities of the PT or APTT before invasive procedures. When indicated, a dose of 12–15 mL/kg
should be administered at a rate of 10–20 mL/kg/h with careful monitoring for acute transfusion reactions
or circulatory overload.
 TRIPICU TRIAL

 Non inferiority trial, restrictive transfusion strategy of using packed red cells that were
leukocyte-reduced before storage would be as safe as a liberal transfusion strategy, as
judged by the outcome of multiple-organ dysfunction.
RESULTS AND CONCLUSION

 Hemoglobin concentrations were maintained at a mean (±SD) level that was 2.1±0.2 g per
deciliter lower in the restrictive-strategy group than in the liberal-strategy group (lowest
average levels, 8.7±0.4 and 10.8±0.5 g per deciliter, respectively; P<0.001). Patients in the
restrictive-strategy group received 44% fewer transfusions; 174 patients (54%) in that group
did not receive any transfusions, as compared with 7 patients (2%) in the liberal-strategy
group (P<0.001). New or progressive multiple-organ dysfunction syndrome (the primary
outcome) developed in 38 patients in the restrictive-strategy group, as compared with 39 in
the liberal-strategy group (12% in both groups) (absolute risk reduction with the restrictive
strategy, 0.4%; 95% confidence interval, –4.6 to 5.4). There were 14 deaths in each group
within 28 days after randomization.
 No significant differences were found in other outcomes, including adverse events. In stable,
critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can
decrease transfusion requirements without increasing adverse outcomes.
 In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell
transfusion can decrease transfusion requirements without increasing adverse outcomes.
TRANSFUSION IN PATIENTS UNDERGOING CARDIAC
SURGERY

 Among patients undergoing cardiac surgery, the use of a restrictive perioperative

transfusion strategy compared with a more liberal strategy resulted in non-inferior rates of
the combined outcome of 30-day all-cause mortality and severe morbidity.
TRANSFUSION IN TRAUMA

 Hemorrhage is the most common cause of death within the first hour of arrival to a trauma
center.
 More than 80% of deaths in the operating room, and nearly 50% of deaths in the first 24
hours after injury are due to exsanguination and coagulopathy.
MASSIVE TRANSFUSION PROTOCOL

 Definitions: Replacement of one`s blood volume in a 24 hour period or transfusion of more

than 10 units of red cell concentrate in 24 hours.
 Or, transfusion of 4 or more red cell concentrate within 1 hour when ongoing need is
forseeable.
 Or, replacement of >50% of the total blood volume within 3 hours.
 Transfusion support to loss of >150 ml/min

 In pediatric patients- transfusion of >100% TBV within 24 hours. Or, transfusion support to
replace ongoing hemorrhage of >10% TBV/min, or replacement of >50% TBV by blood
products within 3 h
TRAUMA RESUS

 Determine the severity of hemorrhagic shock (arterial lactate levels, base deficit etc)
 Expedite control of hemorrhage
 Damage control surgery
 Early blood and blood product resuscitation – TEG/ROTEM guided
 Blood product resuscitation ratio – PRBC:FFP:Platelets – 1:1:1.
 Minimize crystalloids
 Consider Tranexamic acid
PREDICTORS OF MASSIVE TRANSFUSION
ETIC
 ROLE OF TRANEXAMIC ACID?

 MATTERS trial A total of 896 consecutive admissions with combat injury, of which 293 received TXA,
were identified from prospectively collected UK and US trauma registries.
 Main Outcome Measures Mortality at 24 hours, 48 hours, and 30 days as well as the influence of TXA
administration on postoperative coagulopathy and the rate of thromboembolic complications.
 Results The TXA group had lower unadjusted mortality than the no-TXA group (17.4% vs 23.9%,
respectively; P = .03) despite being more severely injured (mean [SD] Injury Severity Score, 25.2 [16.6]
vs 22.5 [18.5], respectively; P < .001). This benefit was greatest in the group of patients who received
massive transfusion (14.4% vs 28.1%, respectively; P = .004), where TXA was also independently
associated with survival (odds ratio = 7.228; 95% CI, 3.016-17.322) and less coagulopathy (P = .003).
 Conclusions The use of TXA with blood component–based resuscitation following combat injury results
in improved measures of coagulopathy and survival, a benefit that is most prominent in patients
requiring massive transfusion. Treatment with TXA should be implemented into clinical practice as part
of a resuscitation strategy following severe wartime injury and hemorrhage.
CRASH-2

 This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211
adult trauma patients with, or at risk of, significant bleeding were randomly assigned
within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of
1 g over 8 h) or matching placebo. 
COMPLICATIONS OF TRANSFUSION

 FEVER (FNHTR)
 HEMOLYTIC REACTIONS
 SPREAD OF INFECTIONS
 AIR EMBOLISM
 TRALI
 TACO
 TRIM
 GVHD
TRALI
 An antibody-mediated reaction between recipient granulocytes and anti-granulocyte antibodies from donors
who were sensitized during pregnancy.
 An antibody-mediated reaction between recipient granulocytes and anti-granulocyte antibodies from donors
who were sensitized during previous transfusion.
 TRALI is caused most often when anti-HLA class I and anti-neutrophil antibodies from blood products are
passively transfused to a recipient.
 The subsequent antibody-antigen reaction in the recipient activates complement, and C5a produced during
complement activation promotes neutrophil aggregation, margination, and sequestration in pulmonary
microvasculature.
 The entry of neutrophils into the lung damages and increases permeability of the pulmonary
microvasculature, leading to pulmonary edema.
 Dypsnea-Hypoxemia-hypotension -fever along with physical findings of bilateral pulmonary edema, even
many hours after the actual transfusions.
ARTIFICIAL RBC`S
HEMOGLOBIN BASED OXYGEN CARRYING DEVICES
THANK YOU