Blood Products



Ultimate goal of blood management is to AVOID allogenic blood transfusion




Increased infection rate

- demonstrated in THR

- decreased killer T cells

Increased risk disease transmission

Increased risk transfusion reaction

Increased post-op fever and antibiotic requirements

Increased cost

Increased hospital stay


Transfusion Recommendations


American Society of Anaesthetists


1.  Hb < 6gm/dL


2. Hb > 6 if

- cardiorespiratory disease

- artherosclerotic disease (heart / kidney / legs)

- condition requiring higher oxygen carrying capacity

- symptoms attributed to anaemia


Allogenic Blood Products


1.  Whole Blood

- single donation or Unit

- citrate as anticoagulant (binds Ca which is required by the clotting pathway)

- stored < 5/52 at 4°C


2.  Packed Red Cells

- 2/3 of plasma removed

- volume 300ml

- haematocrit = 70% (double that of blood)

- can removed WCC if wish (decrease antigen load)

- Hb rise of 1g/dL / Unit


3.  Fresh Frozen Plasma / FFP

- platelets removed

- frozen to preserve labile coagulation factors

- should be ABO compatible



- massive transfusion

- coagulopathy / DIC

- warfarin reversal


4.  Cryoprecipitate

- prepared from FFP by slow thawing at 5°C

- contains F VIII / Fibrinogen / VWF

- usual dose is 10-30 U





- Advanced Liver Disease


5.  Factor VIII Concentrate


Freeze-dried powder

- pooled product -> high risk disease transmission

- recombinate product



- gold Standard Haemophilia A

- preferred in VWD


6.  Factor IX Concentrate


Prothrombin complex concentrate

- contains IX, X & II

- also high disease risk



- haemophilia B


7.  Platelets


Harvested from fresh blood

- may be pooled or unpooled

- store at room temperature for 5/7

- ABO & Rh specific



- platelet count < 20 000/mm3 with bleeding

- 1 unit of platelets raises the platelet count of a 70 kg patient by about 7,500x109 / litre


Transfusion Risk






Viral – HIV. B. C.

Non Haemolytic







Pumonary oedema

Prion CJD






1.  Non Haemolytic Transfusion Reactions


Most common

- 2% to 5% of all transfusions


A.  Febrile reactions


Most common

- result from the recipient's antibody response to leukocyte Ag in the donor blood



- chills, fever, headache, myalgia, nausea, and, occasionally, severe rigors



- supportive

- rarely requires cessation of the transfusion


Leukocyte-removal filters

- diminish the likelihood of febrile reactions

- use of such filters is expensive and retards blood flow

- should be reserved for those patients who have had at least two adverse reactions


B.  Allergic reactions


Most are mild, consisting only of slight urticaria


Laryngeal oedema and bronchospasm (anaphylaxis)

- much less frequent            

- occurring in less than 1% of such reactions


Treatment is supportive

- subsides spontaneously within several hours of the transfusion

- if multiple severe allergic reactions to transfusions are at high risk of developing further reactions

- ameliorated by using washed components


2.  Haemolytic Transfusion Reactions


Risk range from 1:4,000 to 1:25,000



- 1: 100 000


Almost always from mislabelling

- ABO incompatibility

- destruction of the donor RBC


A.  Acute


Clinical features

- chills, fever, chest pain, and flank pain

- nausea, hemoglobinuria, shock, a sense of impending death

- tachycardic and hypotensive


Consequences may be fatal

- effects of intravascular hemolysis on the renal and coagulation systems



- immediately stop the transfusion

- return the unused blood and a sample of the patient's own blood to the blood bank for re-crossmatching



- haemoglobin concentration

- platelet count

- partial thromboplastin time

- serum fibrinogen level

- serum potassium levels


Treatment Hyperkalemia

- diagnose on ECG (depressed ST segment, inverted T waves, U wave)

- hydration with generous administration of fluids and diuretics

- monitor urinary output - maintain out put at 75–100 ml/hour

- IV lasix may be necessary to maintain adequate renal perfusion

- consider transferring the patient to an ICU


B.  Delayed


Less dramatic


Initial survival of transfused erythrocytes, followed by hemolysis within 1 to 7 days


Continued occult blood loss from a traumatic or surgical source

- rule out delayed hemolytic transfusion reaction as a possibility


3.  Metabolic


A. Circulatory overload


B. Coagulopathy


Dilution of platelets and coagulation factors

- no platelet function at 2/7 in packed cells

- F VIII at 30% after 5/7

- F V at 50% after 14/7


Need to give FFP and Platelets with massive transfusion

- > 1 whole blood volume

- > 6 Units Packed Cells




D. Metabolic disturbances



- excess citrate forms complexes with serum citrate




Citrate toxicity

- metabolic alkalosis


- acidosis


E.  Hypothermia

- warm bags of blood in massive transfusion




Transfusion related acute lung injury

- respiratory distress seen after 1 / 2000 transfusions

- development within 6 hours

- may progress to ARDS - like picture



- caused by anti - granulocyte antibodies

- react to donor granulocytes in plasma


Higher incidence in pregnancy

- may be best to use plasma only from men in this situation


D.  Infective


A.  Bacterial

- rare

- 1 : 500 000 RBC (Yersinia, Serratia)

- 1 : 50 000 platelets (Staph, E coli)



- risk 1 in 2 million


C.  Hep B

- risk 1 in 250 000


D.  Hep C

- risk 1 in 2 million


Minimising Transfusion Requirement



1.  Minimise intraoperative blood loss

2.  Cell saver

3.  Reinfusion drain

4.  Haemodilution

5.  Antifibrinolytics

6.  EPO

7.  Allogenic blood transfusion


1.  Minimizing Intraoperative Blood Loss



- careful operative exposure through avascular tissue planes

- good hemostasis using an electrocautery and ligatures 

- short operating time

- judicious use of collagen pads

- sterile bone wax

- tourniquets

- use of topical agents

e.g.  thrombin packs thrombin powder, Gelfoam, adrenaline soaked gauze, fibrin glue


Hypotensive Anaesthesia


A series of 24 Jehovah's Witness patients had a 30% reduction in intraoperative blood loss with the use of hypotensive anaesthesia

- combined use of narcotic and inhalant anaesthesia

- epidural / spinal

- positioning the patient to reduce engorgement of blood vessels


2.  Cell Saver



- lost blood is collected by aspiration or drainage

- filtered / Washed / Centrifuged

- transfused back to patient



- intra-op salvage can return up to 60% of lost red blood cells

- good in spine / acetabular fracture / revision hip

- any surgery where large quantities of blood loss expected



- expensive equipment

- need technical expertise to run

- may not be cost effective



- cell hemolysis

- air embolism



- malignancy

- sepsis




Elawad Acta Orthop Scand 1991

- RCT of cell saver in THR

- 75% reduction in allogenic blood transfusion


3.  Reinfusion Drain



- blood collected in closed system drain

- filtered but unwashed

- re-infused within 4 - 6 hours




Cheng et al J Orthop Surg 2005

- RCT of reinfusion drain

- significantly reduced allogenic blood transfusion rates


4.  Haemodilution



- pre-operative or intraoperative venesection of 1-2 units

- blood volume replaced by crystalloid or colloid

- post-op reinfusion



- intra-operative blood loss is diluted



- hypovolaemia

- anaemia

- cardiovascular disease


5.  Antifibrinolytics



- Aprotinin / E-aminocaproic acid / Tranexemic acid




Wong et al JBJS Am 2010

- RCT of topical application of tranexemic acid

- injected into the TKR at end of procedure

- reduced postoperative bleeding by 25%


6.  Recombinant human erythropoetin


Natural erythropoietin


Secretory glycoprotein of 165 amino acids

- secreted by the kidney

- in response to hypoxemia and hemorrhagic stress

- binds to receptors in the bone marrow

- stimulating the production of red blood cells




Pre-operative EPO shown to

- increase hemoglobin

- facilitate pre-op autologous blood

- markedly decreased allogenic blood needs





- approximately $500 for each half point of Hb raised




Krackow et al Orthopedics 2002

- EPO in total joint patients

- 3 doses pre-operatively

- matched to control group of patients

- Hb average 1 point higher

- transfusion rate halved


7. Autologous Blood Donation



- multiple serial autologous donations may be obtained

- donor's hemoglobin level must be at least 11 g/dl



- pre-existing medical conditions

- advanced age

- low pre-op Haematocrit or Hb

- poor erythropoetic response to phlebotomy



- 60% inadequate erythropoetic response post phlebotomy

- patients who donate blood pre-op are more likely to need transfusion earlier and more frequently

- high cost

- logistical obstacles of storage, collection and transfusion

- high number of bags never used approx 50%


Decision Making Jehova's Witness          




Doctor must act with a proper duty of care

Must act in patient's best interests

Really an informed consent issue




Patient confused with shock

- crying out that he is a JW and doesn’t want blood

- doctor can override if he feels patient not in sound state of mind

- unless patient or family has an advanced health directive


Adult patient fully mentally alert

- doesn’t want blood

- can’t give blood


Child presents needing blood to survive

- parents refuse saying child is JW

- doctor can override if he feels that child not old enough to fully appreciate consequences


Unconscious patient with bracelet saying JW and no blood

- doctor may override if condition life threatening

- only advanced health directive which is carried on person stating refusal for blood will be accepted