Blood Component Therapy - Assignment Example

Blood Component Therapy” The use of donors blood in surgery: Elective Surgery Elective surgery is a kind of surgery that is not an immediate requisite or owing to any kind of urgent situation. This surgery is executed for medical reasons e.g. a person undergoing orthopedic surgery encompassing joint replacement, plastic surgery, cosmetic surgery, splenectomy, cataract operation, or breast implants. These surgeries are solely on the inclination of the patients and they are not critical or vital but are only supportive. It is manifested that the demand for blood and blood products is on a rise. One of the major reasons for this rise is the elective surgery. It has been observed that there is a disorganized practice to place the orders for blood requirement in elective surgeries moreover incidence show a wasteful use of blood in the execution of elective surgeries (Gianoutsos, 2008). It is therefore essential that there should be an approach of “group and screen” procedure compared to going for the full cross-match once transfusion is compulsory and therefore orders must be placed accordingly (Gianoutsos, 2008). In order to avoid the occurrence of hepatitis and HTLV-III infections, an approach of predeposit autotransfusion was realized specifically in elective surgery. This facilitates the conservation of homologous blood and creates an awareness and understanding for the proceeds of autotransfusion (Rebulla, 1987). This kind of approach finds its way through the advancement in the use of preservatives. The method has the advantage over the homologous transfusion where an individual receives the donor’s blood and hence risk life with hepatitis (risk is 46%), malaria, syphilis, allergic reaction (risk is 20 -25%) and mismatches due to any technical errors (risk is 61%). It is therefore essential for planned surgeries to have an autologist transfusion of blood to eliminate risks as it speed up the healing process (Holm, 1981). In order to find out the extent to which autologous blood that has been donated in advance and is used by the patient during the process of elective surgery, a study was carried out where 4996 patients undergoing elective surgery, of these, 1287 patients placed order for cross-matched blood even though 590 patients were found to be suitable for predepositing blood suggesting unawareness about predepositing blood. Merely 5% (32 patients) of the patients predeposited the blood, still 4 amongst these got homologous blood. The study concludes that by predonation of blood 68% homologous blood transfusion could have been avoided (Toy, 1987). This is autologous transfusion (blood collected from the individual before surgery and then re-transfused in the same individual during the elective surgery) prevents any external antigens, infectious agents and moreover zero chances of HIV transmission. Autologous transfusion encompasses: 1. Preoperative Blood donation. 2. Intra-operative collection of blood which includes: a. Perioperative hemodilution b. Intra-operative blood 3. Post Operative blood collection (Blood Transfusion Council) The process of using donor’s blood in elective surgery checks the likelihood of transmitting infections viz. HIV, hepatitis, Treponema palladium. This also checks the alloimmunization to RBCs, WBCs, Platelets and plasma proteins. This practice is essential to add to the inventory stock which could be a great help accidental/ trauma/emergency surgeries. Autologous transfusions aids in preventing allergic and febrile reactions, moreover it excite bone marrow to enhance the production of blood cells (Blood Transfusion Council). The process does hold some disadvantages too which if kept in mind by the physicians can prevent anemia and hypovolemia in patients undergoing surgery. There is always a chance of clerical errors, care for correct labeling, storage of blood and reinfusion of blood. In case when blood is not required when surgery is executed then there is an imposition of blood loss. If due to certain circumstances the operation is postponed, there is a loss of transfused blood as autologous transfusion is done when surgery is to be executed within 35-42 days, if storage is prolonged then it becomes ineffective. In order to avoid this written advice is required from the physician and the blood donated must carry a logo “For autologous use only” (Blood Transfusion Council). There are certain eligibility criterions for autologous donations: 1. Hemoglobin: The most permissible range is ~ or >11gm/dl or 33% hematocrit. 2. Age: no age limit is set but a donor having average weight of 60kg can donate 450ml of blood, i.e. 8-9ml/kg body weight. 3. Rate of donation: weekly or at 4 days interval and the last phlebotomy must be carried out before 72 hours, thereby letting the patient plasma to be back to normal. The period should be supplemented with oral iron dose along with erythropoietin to restore the level of hemoglobin (Blood Transfusion Council). Thus, autologous blood transfusion is the most secure method of blood transfusion. It reduces the requirement for reservoir blood. If appropriate care is taken then this resolves the dependency on blood bank for the execution of surgery. This enables the bank to pool blood for the use in emergency surgeries. Storage of Blood Components Strict transfusion policies have paved the way for reduction in transience of patients undertaking surgery. Presence of any kind of contamination in the form of leucocytes or leukocyte products or due to nonviable or improper RBC functioning provides negative impact on the blood transfusion. This could be improved by improving the quality of RBCs, by removing the leukocytes from platelet concentrates. This is imperative due to high immunogenicity and ability to generate cytokines in the available storage conditions. The advantage of pre-storage leukocyte removal lies in eliminating bacterial contamination of PCs, this does not result in toxin production and therefore fatal consequences could be prevented by adopting routine bacterial culture of platelet concentrates (Hogman, 1999). Whole blood is collected in a bag with anticoagulant- citrate phosphate dextrose. Sterile conditions must be sustained all through the process of blood collection. After collection blood could be maintained in its natural form or is converted into various blood components encompasses packed RBCs, platelet-rich plasma, platelet concentrates (PCs), frozen plasma, fresh plasma, fresh frozen plasma, cryoprecipitate and cryosupernatant. In order to separate the components of blood, 2-4 bags along with satellite bags are required (Blood Components). Blood components are imperative for maximizing the yield of products and to use these products for particular diseases. These components encompass whole blood, packed RBCs, fresh frozen plasma and cryoprecipitate. Blood components encompass: Whole blood: this is the blood collected from the donor directly into the transfusion bag having anticoagulant, citrate-phosphate-dextrose with or without Adenine. It is directly stored at 4°C for either transfusion or for separation of blood components (Blood Components). Packed RBCs: they serve as the source of RBCs which are otherwise present in small amount in plasma. They are procured by centrifugation of whole blood. It is highly efficient for anemic to enhance their oxygen-carrying capacity. They are either used as dilution in isotonic solution for infusion or are stored at 4°C for future use (Blood Components). Additives: encompass dextrose, mannitol and adenine, required for the metabolism of RBCs, added in a sterile manner. They reduce the lysis of RBCs. Platelet-rich plasma (PRP): They are generated by separating plasma from RBCs through a slow spin. They help to cure disorders where platelet number is reduced or they do not function properly (Blood Components). Platelet concentrates: they are produced by separating plasma from platelet-rich plasma. Platelet-poor plasma (PPP): it is produced by separating plasma from RBCs. Fresh plasma: it is platelet-poor plasma, separated from RBCs. Fresh frozen plasma (FFP): it is PPP separated from RBCs in 6 hrs. It is rich in all coagulation factors and plasma proteins like albumin. It can sustain up to 1 year (Blood Components). Cryoprecipitate (CPP): it serves as the resource for various blood proteins like von Willebrand factor, fibrinogen, fibronectin and factor VIII. It is generated by slow thawing at 4°C pursued by centrifugation again at 4°C. All the blood proteins precipitate and are then preserved (Blood Components). Cryosupernatant (Cryosuper): it is the part left after all the cryoprecipitate is removed. It includes coagulation and plasma proteins. It has the advantage as it can be stored at -20°C for 5 years. Frozen plasma: it can be stored for as long as 1 year (Blood Components). Pre-transfusion testing It is essential to have a pre-transfusion testing. RBCs that are transferred must have enough survival intervals when transfused. Pre-transfusion testing encompass ABO and Rh types of patient and the donor It is essential to monitor serum of patient and also of the donor for RBC alloantibodies and then executing a crossmatch to ensure ABO compatibility and to identify clinically significant RBC alloantibodies. It is impossible to overcome all the reaction as very few harmful reactions do occur due to serological inaptness (Huh, 1994). American Association of Blood Banks (AABB) in 1978 emphasized the conditions to carry out blood testing during the pre-transfusion process. The following tests are performed: Blood sampling and clerical checking: it is essential that clerical errors must be reduced to zero as they may turn out to be deleterious. Therefore appropriate measures must be taken to label the samples for truthful and precise serological testing and secure blood transfusion. It is essential for the medical technologist to confirm the information provided on the label of the sample as soon as it reaches the laboratory. The tests must incorporate serological history of the patient along with all the tests. In case any kind of incongruity is found then it must be sorted out before sending the blood for transfusion. This is the most vital step as it can prevent the fatal consequences (Huh, 1994). Blood Grouping: This the test which determines the kind of blood the sample contains. It provides the information about the donor and also the anticipated receiver. For the determination of ABO group, anti-A and anti-B reagents are used and for determining Rh type, anti-Rh or anti-D is used. Determination of Rh-factor is very imperative as if Rh-negative individual gets Rh-positive blood then it will result in fatal consequences. It is therefore critical to label the blood correctly in order to avoid the occurrence of any disaster. Rh-positive blood must be labeled carefully and similarly the Rh-negative blood along with the blood group. This is also called as blood typing. The four groups into which ABO is divided encompass Blood group A, Blood group B, Blood group AB and Blood group O. All the alleles of the blood group are genetically transferred from parents to the progeny and therefore carry genetic significance (Huh, 1994). Antibody detection tests: It is essential to test the serum or plasma of the individual against a single-donor suspension of unspooled, group O reagent RBCs, as they hold blood group antigen for the determination of alloantibodies able to give reaction at 37°C. The serum is tested for anti-IgG using antiglobulin technique (IAT) also(Huh, 1994). It is essential to understand that these antibody screening tests are not capable of determining all the clinically noteworthy antibodies. The tests may fail to see antigens which are fewer in number. On the other hand dosage-effect antibodies are dependent on the homozygosity of genes; they encompass anti-Jka, anti-Jkb, anti-Fya, anti-Fyb, anti-C, anti-E and anti-c. This is significant in terms of selecting the specificity of the antibody of the donor. It is essential to screen the sample for the presence or absence of antigens so match with the corresponding donor/ recipient (Huh, 1994). Cross-matching tests: in order to avoid any kind of transfusion related problems it is essential that crossmatch must be carried out after antibody detection. In this test receiver’s serum with RBCs are tested with those of the donor. If the rest is screened as negative for RBC alloantibodies and those who do not hold any history of such antibodies then a spin crossmatch (IS-XM) is performed to authenticate ABO compatibility. In such cases AHG phase is not essential. On the contrary if the reaction comes out to be positive for RBC alloantibodies or those who possess the history of clinically significant antibodies, AHG test (AHG-XM) is essential. Under both the circumstances, i.e. AHG-XM, IS-XM, incubation at 37°C for 30 mins is performed followed by IAT and anti-IgG. Research highlights the consequences of missing out clinically significant antibodies (Huh, 1994). Computerized Cross-matching: with the increase in demand and advent of improved technologies it is convenient to use computer aided cross matching. This is further approved by AABB. Computer aided detection helps the individuals to detect ABO incompatibilities much ahead and thereby avert the liberation of ABO-incompatible blood components for transfusion. AABB has set certain limitations for computerized cross-matching, and should be performed only when: 1) The patient’s ABO group has been determined two times. 2) The computer database contains all the required information of the donor like ABO group, Rh type etc. 3) The entry of the data should be correct. 4) Incase if any kind of discrepancy between the donor’s blood labeling group and the laboratory confirmatory tests is noticed then computer must convey an alert signal to the user in order to avoid the release of such blood for the transfusion (Huh, 1994). “Type and Screen" Policy: if the donor’s record is fed in the database then it becomes easier for the user to trace out all the details of the donor’s blood (Huh, 1994). With the awareness about the HIV and its transmission through the blood transfusion it is essential to conduct the test for the presence of HIV in the blood sample. This should be strictly performed as any kind of carelessness can lead to fatal consequences and make the receiver HIV-positive. It is therefore essential for all the laboratories to perform HIV test to confirm the absence/ presence of HIV in the blood sample. If the sample/ individual are found to be HIV-positive then the blood sample should not be accepted for donation (Huh, 1994). Pretransfusion testing is essential as the life of the receiver is dependent on the transfused RBCs. It is the prime duty of any blood bank to take all the measures in utmost consideration to avoid any kind of clerical errors for the safe transfusion. It is essential for the blood bank to maintain the temperature and labeling protocols and test every sample with precision to avoid any kind of mishap due to blood transfusion (Huh, 1994). Life depends on blood any kind of urgency must be taken into consideration to carryout transfusion of blood. Irresponsibility or any discrepancy must be reported immediately. The blood bank should keep a trace and record of the samples and the test they carry out for reference. If all the measures are taken care then any kind of problem could be avoided and surgeries and transfusions could be carried out with fewer complications. References Blood Components. Available at http://diaglab.vet.cornell.edu/clinpath/modules/coags/comp.htm [Accessed on 4th February 2010]. Blood Transfusion Council. Available at http://mahasbtc.aarogya.com/index.php/history-of-blood-transfusion/blood-transfusion/autologous-blood-transfusion. [Accessed on 2nd February 2010] Gianoutsos, M. P., Thompson, J. F., Storey, D. W., Kronenberg, H. 2008. The Rational Use of Homologous Blood in Elective Surgery. ANZ Journal of Surgery. Vol. 62 (4), pp 266-269. Holm, D. 1981. Doctors urge patients to use own blood. Available at http://news.google.com/newspapers?nid=1798&dat=19810701&id=JioeAAAAIBAJ&sjid=fI4EAAAAIBAJ&pg=6850,89619 [Accessed on 2nd February 2010]. Hogman, C. F. 1999. Storage of blood components. Curr. Opin Hematol. Vol. 6(6), pp 427-31. Huh, Y. O. 1994. Pretransfusion Testing of Red Blood Cells: Current Status. Available at http://www3.mdanderson.org/~citm/H-94-01.html [Accessed on 5th February 2010]. Rebulla, P., Giovanetti, A. M., Mercuriali, F., Sirchia, G. 1987. Autologous blood predeposit for elective surgery: An Italian experience. World Journal of Surgery, Vol. 11(1), pp 47-52. Toy, P. T., Strauss, R. G., Stehling, L. C., Sears, R., Price, T. H., Rossi, E. C., Collins, M. L., Crowley, J. P., Eisenstaedt, R. S., Goodnough, L. T. 1987. Predeposited autologous blood for elective surgery. A national multicenter study. The New England Journal of Medicine. Vol. 316, pp 517-520. Appendix Consent for Predeposit Autologous Blood Donation 1. .... I, Mr./Mrs./Miss………….…son/daughter/wife of………………………….have been explained fully the purpose and the procedure of the autologous transfusion, and the possibility and the nature of its complications. 2. I consent for withdrawal of my blood by an authorized member of the staff of the blood bank for autologous transfusion. If I do not require transfusion of the blood withdrawn for autologous transfusion, it may dispose off as per the hospital policy. Date:                                                                                                  Patient / Donor signature Witness signature Parent/Guardians signature (if patient is minor) (Blood Transfusion Council). Read More