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Indian Journal of Transfusion Medicine
  Indian Journal of Transfusion Medicine Indian Journal of Transfusion Medicine

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Component Therapy

                                                                                                     Dr. Aseem Kumar Tiwari

                                                                                                                                                                                            MD

 INTRODUCTION

There are few very important reasons why we need to understand and talk about the national use of blood. They are scarcity of this resource, inherent risk of transfusion therapy, and scientific   propriateness of the therapy.

Karl Landstiener said that ‘A blood transfusion should  never be ordered unless it is worth the risk’. Then there are few newer concepts like single unit of blood is therapeutically insignificant and that blood, which is older than three days is safer especially with regards to syphilis.

It is pertinent to know the physiology & management of blood loss before we go any further. Blood  omponents are required only when the loss is greater than 25% of the blood volume & anchor-sheet of management is controlling loss & maintaining normovolemia.

The strategies to ensure rational use of blood are:

1.  Developing guidelines for rational use of blood components & promoting component therapy

2.  Encouraging autologous transfusions

3.  Managing inventory of blood components

4.  Ensuring availability and accessibility to blood components/products and drugs

5.  Organizing clinician awareness programs

6.  Setting up hospital transfusion committee

7.  Transfusion AuditA

Fluid Therapy:

Amongst the fluids used for resuscitating patient with blood loss Crystalloids like Normal saline or Ringer’s lactate are the cheapest & most easily available fluid; they are used first when blood loss is between 15% to  25 %; the only disadvantage is that it is hypo-oncotic and to replace one liter we need to be infuse three times  as much. Colloids like albumin, gelatin, dextran & HES are iso-oncotic but expensive. The human plasma  carries all the risk of Transfusion Transmissible Infections (TTI) & the cost is intermediate.

Pharmacological Agents:

There are certain drugs, which can be used as an alternative to transfusion of blood products. Vitamin K in Hemorrhagic Disease of New-born & Desmopressin is mild hemophilia & Von Willibrand’s diseases are prime examples

Component Therapy

The component therapy is better than whole blood therapy for three reasons:

1.  Scientifically justified: what is needed is given & what is not needed is not given. In Anemia only red cells are used, without giving unnecessary plasma. 
2.
Different components require different storage conditions; Platelets are stored at 220 C while FFP has to be stored at temperatures lower than -300 C

3. One whole blood when split into three or more therapeutic units can be used to conserve this scarce resource & provide for more than one patient.  

Individual Components – Usage and Guidelines Red cell containing components:

The indications are acute blood loss; surgery, trauma & radiotherapy & one unit made from 450 ml whole blood would increase the hemoglobin by 1 gm% 

Platelets:

Made from whole blood (Random donor platelets) or by apheresis (Single donor platelets) are indicated in conditions like aplasia, hypoplasia, TTP, DIC, ITP & hypersplenism and the thumb rule for dosage is one unit per ten kilograms of body weight. The guidelines for usage is according to severity;  hrombocytopenia is mild if the count is greater than 50,000 /cumm, (transfusion required only if there is extensive  eneralized bleeding) moderate if the count is between 20,000 –50,000/cumm (transfusion required in case of trauma/surgery) & severe if the count is less than 20,000/cumm (prophylactic transfusions have to be instituted). 

Fresh Frozen Plasma (FFP):

Contains all the clotting factors & is indicated in factor deficiency, warfarin reversal, vitamin K deficiency, TTP, DIC, massive transfusion, severe liver disease, & cardio pulmonary bypass. The usual dose is 10-15ml/kg body weight.

Cryoprecipitate:

This component is rich in factor VIII, fibrinogen etc & is primarily used in congenital bleeding disorders like Hemophilia or acquired ones like DIC. Thumb rule for dosage is one unit /6 kg body wt. 

Autologous transfusion

It reduces the demand of allogenic blood, is absolutely safe because it cannot transmit TTI or cause allergic reactions. There are three standard techniques involved, pre deposit preoperative hemodilution and peri-operative blood salvage. 

Inventory Management

The basic principle of inventory management is First In First Out (FIFO). Only exceptions are Neonates, Thallasemics & bypass surgery patients. 

If plasma depleted red cells are used it gives the flexibility of using compatible cells as against same group for eg. AB group patient can receive cells from any blood group donor, AB, A, B and O. 

Platelets & Cryoprecipitate can be used non-group specific; plasma has to be mainly ABO compatible. 

Awareness Programs

Awareness of blood components, indications, dosage,  guidelines, alternatives to blood like  harmacological agents & autologous transfusion, would lead to judicious usage of blood. 

Hospital Transfusion Committee

The committee has the role of formulating policies, developing guidelines, monitoring supplies & adverse effects of blood transfusion & auditing the services & practices. 

Transfusion Audit

Audit includes analyzing data to find a trend and then taking appropriate actions. One very good example is the case of a hospital, where they found that FFP was being used inappropriately. The Transfusion Committee agreed upon and decided that they shall mention PT & APTT on requisition form & only when these values are 1.5 times the normal value, FFP would be issued. This exercise brought down the unjustified usage of FFP drastically. 

Summary

Rational use of blood is about using the right product, in the right dose, at the right time and for all the right reasons.

 

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Dr. Aseem Kumar Tiwari
MD
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