INDICATIONS AND CONTRAINDICATIONS FOR HAEMOTRANSFUSION

Proceeding from the mechanism of transfused blood action, there are certain absolute and relative indications for haemotransfusion. But if the question is about haemotransfusion after blood loss, which has an obvious threat to the life of the patient, any contra-indications are not taken into consideration. Indications to haemotransfusion are following:

а) acute anemia (hemorrhagic shock) in the case of a decrease in the level of haemoglobin by 1/4 and a decrease in ABP lower than 80 mmHg. In pediatric practice the following calculation is applied: the body weight in kg is multiplied by 25 ml and by the units which does not suffice up to 10 g% of haemoglobin;

bringing a patient out of traumatic shock and during large operations with the purpose of fighting against postoperative shock;

detoxication after poisonings and bacterial insemination, with the purpose of immuno-stimulation;

homeostasis disturbances because haemotransfusion corrects the disturbances of water-electrolytic metabolism;

performing homeostasis with the presence of bleeding: the best thing in this situation is direct haemotransfusion or fresh-citrate blood introduction;

transfusion of blood and its components (plasma) after the exhaustion of the organism with the purpose of nutrition. Contraindications to haemotransfusion are the following:

а) acute infringement of the liver, kidneys or heart functions; inflammatory diseases of the vessels (thrombophlebitis, phlebitis, embolism); allergic conditions; active tuberculosis processes and also inflammatory diseases of the lung tissue.

As it was already marked, all these contra-indications become relative in cases of acute anemia. Certainly, the risk grows; therefore it is possible to apply certain blood components, abrupt transfusion, it is necessary to adjust the speed and quantity of blood which is to be given.

METHODS AND TECHNIQUE OF HAEMOTRANSFUSION

Direct, indirect, reverse, exchange and extra-corporate methods of haemotransfusion are distinguished.

Direct transfusion is the direct use of the donor’s blood, which is immidiately entered to the patient avoiding of the preservation stage. Such blood is the most valuable, but thus there is the danger of infecting the patient with donor’s diseases about which he couldn’t know himself. A number of devices (Beck’s, Juvalier’s), as well as syringes are applied for direct transfusion. The blood transfer from the donor to the recipient occurs under sterile conditions.

Indirect method: the blood is taken from the donor, mixed with a preservative, kept under certain conditions and after 5–10 days is ready for transfusion. Single-use systems, which consist of a set of tubules and filters, are applied for indirect transfusions. The system contains a manometer and gas-cylinder, which allows the creation of pressure (180–200 mmHg) for intra-arterial haemotransfusion.

Exchange transfusion, or reinfusion — the use of blood which was taken from a cavity. In effect this is autotransfusion. Blood without clots and different admixtures is at once put back into the circulatory system of the patient. During reinfusion, the blood is filtered through filters and sterile gauze linings; a small amount of heparin is added. Technically it is carried out like indirect transfusion. Exchange transfusion is applied during acute poisonings (arsenic, mushrooms, carbonic oxide, lead, mercury and other poison). Bloodletting is carried out and then the same amount of donor blood is given.

Thus, a system of approach to haemotransfusion was established. Before haemotransfusion, the doctor should use a number of actions:

To determine the indications for haemotransfusion — the purpose of transfusion.

To estimate possible contra-indications, select the methods ofblood introduction, determine its amount and speed.

To define the blood group and Rh-factor of the recipient andthe donor.

To realize the direct tests for compatibility, to estimate beforehand the eligibility of blood for transfusion.

To make tests for Rh-compatibility.

To check the biological compatibility of blood by jet (thrice) introducin of 15–20 ml of blood with intervals of 3 min.

The special documentation or special report of haemotransfusion are filled in during haemotransfusion. For the control of possible complications measuring of the body temperature during the first 2 h and urine analysis within the first day are carried out.

Proceeding from various indications, it is possible to apply such methods of entering blood: intravenous, intraarterial, intraosseous, through cavernous bodies.

Clinical practice testifies that not always it’s necessary to transfuse the whole blood. Frequently, some of its components are used and sometimes constituents — preparations of blood which are prepared with special technologies.

Blood components are prepared with the help of differential centrifugation of the whole blood. Erythromass (erythrocitic suspension, washed erythrocytes), leukomass, thrombomass, and native plasma are blood components. Erythromass is a preserved blood, from which plasma is removed; it is expedient for anemia. Washed erythrocytes are erythromass where plasma is completely absent. Erythrocytic suspension is the blood which is deprived of plasma, which is replaced with a physiological solution with the addition of chloramphenicolum, rivanol and glucose. Leukocytic-thrombocytic mass received after the centrifugation of blood and leukocytes and thrombocytes are separated.

It is necessary to remember that all preparations which contain erythrocytes are entered into a person’s organism just like preserved blood — observing the rules of transfusion and technique of transfusion. They are the same as for preserved blood. Leukocytic-thrombocytic mass is entered without observing the group type, applied 24–72 h from the moment of preservation, entered intramuscularly. Native plasma is a fluid part of the blood without corpuscular elements. It is obtained after centrifugation of preserved blood. It is kept just like blood, but no more than for 72 h. It is entered with observing the group type. Ways of entering are the same as for preserved blood.

Today, methods of preserving plasma by freezing or drying have been developed. Dry plasma is kept for 3–6 years. Before application, they dilute it with physiological solution or distilled water. They enter it into an organism the same way like blood. Recently, special kinds of plasma (antihemophilic, antistaphylococcus, anti-blue-pus) that are received after immunization of donors with weakened toxins — anatoxins of corresponding activators, are widely used.

Preparations of blood are made of blood plasma. According to the action they belong to haemocorrectors (fibrinogen, cryoprecipitate, antihemophilic globulin, fibrinosin, and thrombin) or preparations of complex action.

Fibrinogen is excreted from plasma, put into bottles by 1 g and it has no group specificity. Before applying, it is diluted with distilled water or a physiological solution, entered intravenously. Fibrinogen is used for preparing the following medicines of local action: fibrin film, biological antiseptic tampon, haemostatic sponge.

Fibrinolysin — an enzyme extracted from plasma, has the property to dissolve blood clots. Correctors of the coagulation system of the blood, such as thrombin, fibrin film, haemostatic sponge are applied rather widely to stop bleeding by application.

Albumen, protein, serum, specific immunoglobulin belong to preparations of complex action.

Albumen and protein are allocated from plasma as 10% or 25% solutions, they have no specificity. They are entered intravenously, widely applied for treating various intoxications.

Serum is plasma which does not contain fibrinogen. Serum is preserved and entered just like native plasma. Sometimes calcium, vitamins, spirit are added.

Specific immunoglobulins (anti-staphylococcus, anti-tetanic, antiinfluenzal, anti-blue-pus) are allocated from plasma of people who had corresponding diseases or were immunized with weakened toxins. Immunoglobulins have no group specificity, entered intramuscularly.

Blood Substitutes

Some of blood functions can be replaced with various preparations that are biological or chemical derivatives. According to the mechanism of action they are divided into 4 groups:

Anti-shock (hemodynamical) blood substitutes carry out thefunction of filling the circulatory system, restoring the normal blood volume which was disturbed as a result of blood loss or shock. Low and average-molecular dextran (rheopolyglucin, polyglucin) and compounds of gelatin (gelatinolum, haemogel, plasmogel, etc.) belong to this group.

Desintoxication blood substitutes which are used in treatingintoxications of various genesis (poisoning, endotoxicoses of various origin, burn and radiation sickness). Compounds of low-molecular polyvinylpyrolidone (haemodes, neohaemodes, periston, neocompensan) or polyvinyl spirit (polydesum) belong to this group.

Preparations for parenteral feeding which are applied in treating protein insufficiency, and also for correcting nutrition during the postoperative period in patients with operations on gastrointestinal tract. Albuminous hydrolysate (casein hydrolysate, hydrolysin, aminocrovin, aminopeptide, amikin, aminosol, aminon), mixes of amino acids (polyamine, moriamin, aminofusin, vamin, friamin), fatty emulsions (lipofundin, intralipid, liposalve), and also saccharum and multinuclear spirits (glucose, sorbitol, fructose) belong to this group. Hydrolyzine, hydrolyzate casein, amynocrovin are not applied now, as they cause often collateral reactions and are withdrawn from production.

Regulators of the water-salt metabolism are applied for oligemia to increase osmotic pressure for treating infringements in the water-electrolytic metabolism, for improving rheologic properties of the blood. They are applied for different kinds of shock: dehydration, intoxication. Various salt solutions: Ringer solution, isotonic solution of sodium chloride, trisaminum, lactosolum, disolum, trisolum, chlosolum, etc. belong to this group.

Ringer solution: sodium chloride — 8.0 g kalium chloride — 0.075 g calcium chloride — 0.1 g distilled water up to 1 l Ringer—Lock solution: sodium chloride — 9.0 g sodium bicarbonate — 0.2 g kalium chloride — 0.2 g calcium chloride — 0.2 g glucose — 1 g bidistilled water up to 1 l Lactasol: sodium chloride — 6.2 g sodium bicarbonate — 0.3 g kalium chloride — 0.3 g calcium chloride — 0.16 g magnesium chloride — 0.1 g sodium lactate — 0.3 g distilled water up to 1 l

Recently, blood substitutes with function of transferring oxygen have been developed and improved clinical usage (hemoglobin emulsion), which will appreciably help in the application instead of the whole blood in the near future.

Complications during Haemotransfusion and Preventive Measures

Blood and its preparations, which are powerful stimulators of vital activity of an organism, are not deprived of some negative qualities and cause serious complications. As a rule, the complications arise when under circumstances the rules of haemotransfusion are infringed. Sometimes underestimation in the condition of the patient, violation of conditions of blood preservation and transfusion technique are damaged. So, disregard of the diseases from which the donor suffered in the past, ignoring of a number of clinicalbiochemical investigations of the donor’s blood can lead to infection of the patient with hepatites, malaria, syphilis, sepsis, AIDS and other infectious diseases.

Incorrect blood preservation, lack of sterility, deranged ratio of preservatives and blood can lead to sepsis, thrombembolia. Infringement of the rules for the techniques of haemotransfusion can cause inflammation of the vascular walls (phlebitis), air or thrombembolia. Ignoring the accompanying diseases can lead to their exacerbation (nephritis, hepatites) or cause cardiac activity decompensation in patient. Under long preservation of blood, infringements of the preservation temperature can bring to haemolysis of erythrocytes, change in the protein structure, which is found in pyrogenic reactions. They can be mild (rise in the body temperature by 1°С), moderate (by 1.5–2°С), severe (greater than by 2°С). Usually these complications are observed 10–15 min after the start of haemotransfusion (fever, pain in the back, faintness). Treatment is in immidiate stoppage of haemotransfusion, introduction of desensitized preparations (chloric calcium, dimedrol, pipolphenum), it is necessary to warm the patient, to give pyramidon, analginum. In case of increased protein sensitivity of an organism and disregard of biological test there can be allergic reactions, itching, rash, hypostases, rise in the temperature, shortness of breath, and sometimes anaphylactic shock occurs. Thus vomiting, damage in breathing, falling of the arterial pressure, bronchospasm, oedema of the lungs may occur. With the presence of these symptoms transfusion is stopped, the patient is given the mentioned preparations and in a case of anaphylaxis — glucocorticoids, cardiac preparations; patients are administered artificial breathing (apparatus).

The most difficult complication is post-transfusion, or haemotransfusion shock which can arise as a result of incompatibility of blood group or Rh-factor, and also after the introduction of a large amount of haemolyzed blood. During transfusion of incompatible blood fever, faintness, pain in the chest, decrease in arterial pressure, rise in body temperature, attributes of kidney irritation (albuminuria, hematuria, oliguria, and sometimes anuria), jaundice, renal-hepatic block which results in death, may develop. It is necessary to remember that in the pathogenesis of this complication consists of haemolysis of entered erythrocytes.

Sometimes this complication develops quickly or can sometimes appear on the 2nd–3rd day after haemotransfusion. It depends upon the doze of the entered blood. If the patient was under narcosis or used desensitized preparations, the development of haemotransfusion shock can take a long time. In case of the occurrence of this complication, haemotransfusion should be stopped; the patient is given a significant amount of liquid, desensitized preparations, and pararenal blockade is carried out. Haemodialysis, sometimes bloodletting and transfusion of the same group of blood are done.

If the Rh-factor was determined incorrectly or the test for Rhcompatibility was not done, Rh-conflict can take place. In newborns this complication is referred to as haemolytic jaundice, sometimes it is called haemolytic shock. The basis of its development is the conflict of the Rh-factor with the Rh-factor — antibody, thus haemolysis of the erythrocytes of the patient and the donor occurs. The clinical picture develops rather quickly and is similar to the clinical picture of haemotransfusion of another group. Successful treatment consists in exchange haemotransfusion, i.e. bloodletting with the following injection of Rh-negative blood which does not contain antibodies.

Active replacement of the lost blood can lead to such complications as citrate intoxication and homologous blood syndrome. Citrate intoxication develops when a significant amount of preserved blood is entered at one time. Hypotension, tachycardia, spasms are found. The reason is in intoxication of an organism by sodium citrate. For prevention of this complication, for every 500 ml of preserved blood 10 ml of a 10% solution of calcium chloride are entered. During liquidation of large blood loss it is necessary to use heparinized blood or direct haemotransfusion.

The homologous blood syndrome develops if for some period of time (days, weeks) a significant amount of blood for liquidation of anemia and blood loss replacement. The basis of this syndrome is the development of incompatibility between leukocytic and thrombocytic antigens. The clinic is thrombocytopenia, leukopenia, the development of DVS-syndrome in different organs and systems of an organism. DVS is a syndrome which is characterized by the development of thromboses against a background of bleedings and depending upon the place of occurrence give the clinical picture of acute renal, hepatic or lung insufficiency (bulked lung) or sharp infringement of blood circulation in the vessels of the brain (haemorrhage with cerebral ischemia) are found. The homologous blood syndrome is the reason for high lethality. For prevention of its development during liquidation of large blood loss, washed erythrocytes need to be used for anemia instead of preserved blood. Thus, blood carries out a very important function in a person’s organism and can be used for treating many diseases. Clinical efficiency of haemotransfusion is generally recognized. haemotransfusion had a long period of studies of blood properties, mechanisms of action in an organism. It should be applied in surgical practice everywhere, but it is necessary to adhere to indications and contraindications of haemotransfusion and to precisely carry out the rules of technique of haemotransfusion.