Pump blood
Pump blood is the blood remaining in the bypass circuit on the completion of bypass. It is a mixture of the patient’s own blood, other fluids and any bank blood used to prime the bypass circuit.
Unfiltered pump blood has a low Hct and contains large amounts of heparin and inflammatory cytokines. The use of CUF (continuous ultrafiltration) during bypass or MUF (modified ultrafiltration) after bypass, concentrates the pump blood and removes some heparin and cytokines. If pump blood is used, additional heparin reversal will be needed. It should not be used if there is excessive bleeding or if the Hb is low.
Protamine sulphate is used to reverse the heparin in pump blood. The dose is 1 mg per 25 ml of pump blood. Recheck ACT after 10 ml/kg pump blood. Rapid infusion may cause pulmonary hypertension.
Packed red blood cells (PRBC)
Each unit of pack cells contains ~ 300ml and has an Hct of 0.5-0.7 (Na+Â ~20, K+Â up to 2 0mmol/l, especially if irradiated)
Warning:Â Neonates should be transfused with blood which is as fresh as possible, and sufficiently slowly to minimise any adverse effect from hyperkalaemia and citrate toxicity (hypocalcaemia).
Used for treatment of anaemia and the management of active bleeding. Must be compatible with recipients ABO and Rh groups and clinically significant red cell antibodies.
Transfusion of 4 ml/kg increases Hb by approximately 1 g/dl. In rapid transfusion situations alternate red cell units with colloid solutions e.g. FFP.
Store only in a designated blood refrigerator (2 to 6°C). Use within 4 hours of removing from refridgerator and always use a leucocyte filter.
Request irradiated products if suspicion of immunodeficiency (e.gg Di George anomaly) or in any neonate <1 month undergoing cardiac surgery.
Donor blood exposes the patient to risk of infection and transfusion reaction. Pump blood, however is blood to which the patient has already been exposed.
Platelets
Cardiopulmonary bypass frequently leads to both thrombocytopenia (dilutional) and more importantly platelet dysfunction (early onset). Platelet transfusion should be considered for excessive bleeding, irrespective of the absolute platelet count. Transfused platelets have a storage (function) defect lasting 2-4 hrs.
Platelet transfusion should not be used for “routine” volume expansion. Should be ABO compatible to prevent haemolysis caused by donor anti-A and anti-B. Female infants and children (all females <45 years) should receive RhD negative platelets. The dose is 10 ml/kg – repeat platelet count and/or TEG.
Fresh frozen plasma
Plasma separated from one donation of blood. Contains normal levels of stable clotting factors, albumin and immunoglobulin. Factor VIII levels are ~70% normal while plasma proteins (immunoglobulins and clotting factors) are slightly diluted.
It should be ABO compatible to prevent haemolysis by donor anti-A or anti-B.
Should be used for microvascular bleeding following massive transfusion or cardiopulmonary bypass, emergency reversal of warfarin effect (in addition to Vitamin K), bleeding resulting from hepatic failure and proven coagulopathy (factor deficiency or DIC).
Loss of clotting factors may occur as a result of excessive loss of peritoneal, pleural fluid or ascites (via PD catheter). If replaced with NaCl 0.9% alone this may lead to a dilutional coagulopathy.
Dose is 10-20 ml/kg IV. FFP should ideally administered slowly (<40 ml/kg/hr) as rapid administration can result in cardiovascular collapse by several mechanisms including calcium chelation by citrate (check patient iCa if concerned).Infection risk similar to other blood components. Transfusion should not be used for ‘routine’ volume expansion.
Cryoprecipitate
The cold precipitated fraction derived from FFP. Contains factor VIII, fibrinogen, von Willebrand factor and factor XIII.
Should be used for significant fibrinogen deficiency associated with clinical bleeding, DIC, trauma or during invasive procedures. Suitable for haemophilia and von Willebrand disease. Dose is 5 ml/kg IV. One bag is usually 20-30 ml. Infection risk is similar to other blood components.
Human albumin solutions
| Albumex 4% | Albumex 20% |
| Protein 40 g/l | Protein 200 g/l |
| Na 140mmol/l | Na 48 – 100mmol/l |
| Volume expansion | Hypoproteinaemia |
| 50, 250, 500ml bottle | 10, 100ml bottle |
| 5 – 10ml/kg aliquots | 5ml/kg aliquots |
Albumex 20% is hyperoncotic and in an ideal situation (ie. normal capillary permeability) should expand circulating volume by a factor of 5.
References:
[1] Cochrane Database Syst Rev. 2011 Mar 16;3: Perel et al: Colloids versus crystalloids for fluid resuscitation in critically ill patients
[2] SAFE Study Investigators, Finfer et al: Effect of baseline serum albumin concentration on outcome of resuscitation with albumin or saline in patients in intensive care units: analysis of data from the saline versus albumin fluid evaluation (SAFE) study
[3] Pediatr Crit Care Med. 2007 Sep;8(5):459-64: Jatana et al: Deletion 22q11.2 syndrome–implications for the intensive care physician
[4] Peditar Crit Care Med 2011 Vol.12, No2: Isthaphanous: Red blood cell transfusion in critically ill children: A narrative review
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