Blood Transfusion

A blood transfusion is an operation consisting in injecting, by intravenous Perfusion, of the Sang or the blood derivatives.

History

The blood transfusion is very old: the history of the former Egyptians and the Treaty of anatomy of Hérophile make mention of it. To the 15th century, the Pape Innocent VIII would have been subjected to this treatment. In the majority of these attempts, blood employed was of animal origin.

In 1492: The pope Innocent VIII undergoes the first “treatment” of alive cells by drinking the blood of three ten year old boys three times per days. The children die then the pope follows them closely.

In 1616: William Harvey, an English doctor was the first to show that blood circulates in the body and that it does not stagnate. That proves that blood is used to transport something but at the time one does not know what yet.

In 1667: Jean Baptist Denis, a very famous French doctor at the time, personal doctor of Louis XIV, is the first to inject the blood of an animal to a man. He injects the blood of a young person Agneau with a man reached of Typhus (Gastro-entérite mortal at that time). The man dies, shortly after what proves to be the first blood transfusion. The same year, Denis and his Emmeretz fellow-member carried out the first transfusion of man with man by connecting the artery of one of the subjects to the vein of the other.

In 1668: The French court decides that only the doctors known as “qualified” will be authorized to make blood transfusions because the majority of the people who profited from transfusions at the time died little of time afterwards. The court also requires before each transfusion at least an animal experiment.

In 1788: One can now show that a dog weakened by a heavy bleeding needs only an injection of blood to be reanimated. Thus the same thing is possible for the men. One knows as now as blood is used to transport essential oxygen for any life.

In 1818: During this year, the first transfusions of blood of human to human take place. The blood of the animals is not used any more because too many patients died. One expects more results with human blood but the doctors at that time did not take into account the blood groups and the Rhesus factor. Thus few chances of success but much more than with blood of animal. The first recipients are women after their childbirth, weakened by the heavy bleeding.

In 1820: The transfusion with animal blood remakes a small appearance because many problems provide like the coagulation of human blood (much faster than that of animal blood) but also of many diseases and epidemics are propagated by human blood.

In 1900: the Austrian, Karl Landsteiner discovers the concept of different blood groups (A-AB-B-O), by comparing the blood of various subjects. He notes that blood binds or not with the red globules of the other patients. From now on the majority of the transfusions succeed. It obtains the Nobel Prize of medicine in 1930.

In 1916: First success by Albert Hustin on the conservation of human blood: by adding soda citrate, it does not coagulate almost any more.

In 1918: During the first War of many progress one made in medicine and in particular on blood. It is during these years that the first “true” transfusions take place with large scales (transfusions while holding count blood groups).

In 1940: Karl Landsteiner and its Wiener compatriot discover together the Rhesus factor of the name of the monkey of race macaque having been used for the experiment. The transfusions become increasingly sure for the receivers.

It is Charles Richard Drew which conceptualized and organized the first Banque of the blood, which made it possible to bring blood to the Britanniques during the Second world war, between 1940 and 1941.

Of 1985 with 1990: Business of blood contaminated: 4400 people are contaminated by the virus of the AIDS after administration of blood products. (see: risks; business of contaminated blood)

In 1993 (January): Many laws are signed to guarantee the safety of the donors and the receivers at the time of the gift and the transfusion. The government wants to encourage the gifts to be able to save the maximum of lives and to avoid a shortage.

In 1998 (April): Systematic filtration of the white globules (deleucocytation) on the total gifts of blood.

In 2000 (January): Creation of the French Establishment of Blood, single operator of the blood transfusion in France. The employees are not voluntary they are remunerated by the State.

In 2001 (July): A very significant systematic tracking (known as genomic) of the Virus of the AIDS and Hépatite C are made before each gift and each transfusion because these diseases are mortals and easily transmissible (not by the air).

Processes

Transfusion of total blood

Homologous transfusions

Blood comes from a human donor other than the patient himself in the conditions which the blood groups are compatible between donor and receiver

Transfusion of globular concentrates

The red globules, the white globules are preserved being eliminated by deleucocytation, thus decreasing the viral and immunological risks.

Perfusion of plate concentrates

Is useful only for the fight against the hemorrhagic disorders, especially in the event of medullary insufficiency.

blood plasma

Its conservation requires congelation (safeguarding of thermolabile proteins) with -25°C. The shelf life of frozen human plasmas is one year. In France, all plasmas resulting from total blood are yielded to LFB (French Laboratory of Fractionation and Biotechnologies) with the Ulis in Paris region. LFB has as a role to extract and purify the molecules necessary to certain patients like the anti factor hemophilic for example. Only plasmas of origin of apheresis (taking away only of plasma in a donor) are tranfusés such as it is. There exist two types of therapeutic plasmas: the PVA (method of inactivation physicochemical) and protected plasma (the gift of plasma are at least insulated 120 days, in waiting of returned from the donor or at this time, it will be checked that all legal markers (HIV, syphilis, Hépatite…) are always negative)

Transfusion autologist

(or autologous transfusion ) in the forecast of a particularly hemorrhagic intervention, it is possible to take blood before a few weeks, to preserve it and inject it during the operational act. The risk of contamination viral is less and there is no immunological risk.

Transfusion of blood recovered starting from the operational bleeding

the recovered red blood corpuscles are aspired, washed and reinjected. This method requires a preparation and special materials and can be addressed only to one particularly aseptic surgery (vascular or osseous) and apart from any cancerous or infectious affection.

Uses

Complete blood is hardly any more used: blood of the donor, one extracts several types of made up:

Red globules

The transfusion of red globules replaces that of total blood today. One can obtain concentrates made starting from total blood. These concentrates can be preserved 42 days at a temperature fixed legally between +2°C and +6°C. One transfuses concentrates of red globules to look after Anémie S low registers. These anemias can be due to many causes (lack of iron, certain vitamins, hemorrhages…).

Plates

One can concentrate the plates starting from total blood several donors (proceeded initial). One can also now take them in a single donor by Aphérèse, i.e. one takes the blood of the donor on an automatic machine which, by differential centrifugation, preserves part of the plates and restores the blood impoverished of plates with the donor.

This technique of apheresis makes it possible to take sufficient plates with only one donor (about 4 X 10¹¹, that is to say 400 billion) to treat a patient. The plates of the donor are regenerated rather quickly because it produces some from 100 to 200 million per minute. The gift of plates is used to treat certain diseases which generate a lack of those; as the Leukemia S and the Aplasie S. leukemias are leukemias. One uses the Chimiothérapie to kill the cancer cells, but that keep silent also nonsick cells, of which plates, from where misses them. Aplasia is a disease where the osseous Moëlle, the body which produces the blood cells, does not do any more its work.

The plate concentrates have one period of 5 days validity under agitation constant and maintained between +20°C and 24°C in order to preserve all their hemostatic activities.

Plasma

The taking away of plasma is carried out by Aphérèse. The process is relatively similar to the taking away of plates, with share which one takes approximately 600 ml of plasma to the donor with which one restores his blood impoverished of plasma.

Once taken, the plasma which is preserved one year at -25°C, either is transfused such as it is, or split in its various elements: the Albumin, the factors coagulants and the Antibody. The antibodies are injected in the event of immunizing disorder (immunizing deficit, auto-immune Maladie…), or to prevent an infection in the event of exposure to a risk of contamination (example: Tetanus, Hepatitis B…). Albumin (a protein) and total plasma are transfused with the badly burned persons which lose them by the skin, and with the seriously injureds. The factors coagulants them, are used to treat certain hemorrhagic diseases: the Hemophilia for example.

Risks and complications

The transfusional risk exists, but remains lower than the risk not to be not transfused if the indication of the latter were posed. The viral risk is apprehended much better since the Nineties, which limited very clearly the recourse to the transfusions since.

The risks are of origin immunological, infectious, or related to transfused volumes:

Immunological risks

transfusional Incompatibility érythrocytaire: it is a priori drawn aside by the tests made on the donor and the receiver.

accident ABO, often serious, should not be seen any more, because perfectly avoidable, and always due to an human error.
out this case, the transfusion is regarded as sure to 98% (one thus has 2% of incidents, of which very little lead to a death. Most frequent of these incidents are a reaction " shiver-fièvre" , momentary and benign reaction).

leuco-plate incompatibility, due to the presence of antibody anti HLA in the donor, which can involve a pulmonary attack engraves, the TRALI, English acronym ( transfusion related acute lung injury ), for transfusional acute pulmonary attack.
will purpura post transfusional, several days after a transfusion of homologous plates. The patient destroys his own plates.

If one transfuses a person with an incompatible blood, that can cause the death of the patient: the Anticorps react and that involves an acute Hémolyse intravascular, with CIVD, Hémoglobinémie (plasma pink or red) and Hémoglobinurie (Urine red dark), and involves a irreversible Collapsus. If the person is conscious, it will feel sometimes a sharp pain with the lumbar ones; during a Surgical operation, one will note a hemorrhage in tablecloth. In some cases, there will be an absence of reaction by Immunodéficience, but also some cases of absence of unexplained reaction. If one realizes some in time, the patient must be treated by Hémodialyse.

Into France, an accident ABO (about fifty case per annum) results in a rate of death from 10 to 20%.

Let us note that in the event of transfusion as a blind man, which was made before the discovery of the blood group, but is also always nowadays practiced in the Pays in the process of development because of the absence of means of analysis, one can estimate that one has approximately 64% of chances that the gift is compatible. If the transfusion is reserved for the serious case, one can thus estimate, while transfusing as a blind man, that one saves two patients out of three.

Infectious risk

bacterial risk, due to the bacterial contamination of the transfused product. This type of accident is rare, but very serious. This transfusional risk radically changed the practices of regulations these last years, involving a limitation of the indications and the research solution alternatives ( autologous transfusion , work on artificial blood…). The most important risk, less controlled, and being able to lead to accidents fatal (first cause of fatal post-transfusional accident, before even accident ABO), are primarily bacterial , the contamination at the time it taking away which can lead at the receiver to Septicémie S or shocks toxinfectious, especially for the concentrates of plates which are preserved at room temperature (22°C) supporting the development of the bacteria. One minimizes this risk by adopting rigorous procedures of asepsis at the time of the taking away, by refusing any feverish donor. The current pockets of taking away would allow a systematic tracking the laboratory without “opening” the container (in oneself, source of contamination), but it is not yet a legal requirement. Moreover one should not lose sight of the fact that the examinations bacteriological require much time, thing sometimes not easily compatible with products at very limited lifespan, like the plates (5 days).

controlled Well better today, perhaps because of the mediatization with excess which proposed it in the Nineties, is the viral risk (Hépatite S viral, MVC, HIV…), which involves only exceptionally today contaminations. That has undoubtedly explained the backward flow for a few years of the request for protocols of differed autologous transfusion (lowers regulations of about 50%, with the profit of the simple homologous transfusion). One minimizes this risk while trying to detect by the interrogation the possible carriers of virus, to reject the “donors at the risk”. The tests of laboratories on the blood taken with the accepted donors, in particular viral tracking genomic, make it possible to still more reduce this risk which currently tends towards zero, while preserving a strong media repercussion.

Three cases of transmission of the disease of Creutzfeldt-Jacob by the means of blood transfusions were described in 2006. These diseases with prion S pose other unsolved problems directly (not of technical possibility of tracking). Only a targeted ousting (previous family, “stopwatch-geography”) makes it possible to minimize, the risk.

These risks in three stages are minimized:

Selection of the donors. Before the gift, the donor has a discussion with a doctor who informs it risks that it makes run to the receiver of its blood if this one is contaminated. This doctor gives also councils and evaluates the disease risk in the donor (it can be in a phase where it cannot be detected). He can refuse the gift (10 to 25% of the cases), advise with the donor to make analyzes of his blood in laboratory or to await a few months the end of a treatment.
Analysis of blood collected. Certain viruses like those of the AIDS and hepatitises B and C are systematically required and certain parasites as paludism can the being according to the geographical past of the donor.
Treatment of blood collected. By filtration or heating, one inactive possible microbes of plasma. Unfortunately one cannot do that for the blood cells (globules and plates) because they would be destroyed.

The traceability of the blood products transfused remains essential in order to be able to go up to the donor in the event of problem.

Other risks

transfusional overload, which can involve a OAP (acute edema of the lung), by excess of volume in circulation. Hypocalcemy due to the citrate overload.
hémochromatose, by iron overload, after hundreds of transfusions.

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