Critical Care Obstetrics part 18 ppsx

Vascular Access
159
ing external pressure on the IJV in the supraclavicular area for 10
seconds. During the application of pressure, the central venous
pressure and waveform were observed. In all cases of catheter
misplacement into the IJV, the central venous pressure increased
3 – 5 mmHg. If the misplaced catheter was in another vessel, the
central venous pressure did not change with this maneuver.
An attempt to compare IJV, SCV and femoral vein sites for
subsequent thrombosis, stenosis and infection suggested that the
SCV site is less often associated with infection, mechanical com-
plications and thrombosis compared to the other sites [60] .
Femoral v ein
From lateral to medial, the femoral nerve, artery and vein traverse
the femoral triangle by descending beneath the inguinal ligament
[46] . The femoral vein can be located 1 – 2 cm medial to the pal-
pated femoral artery pulse. If the femoral artery cannot be pal-
pated, the location of the femoral vein can be estimated by
imagining a line from the anterior superior iliac crest to the pubic
tubercle and then dividing the line into equal thirds. The femoral
artery lies at the junction of the middle and most medial segment
and the femoral vein can be estimated as 1 – 2 cm medial to this
point (Figure 10.7 ). The skin is punctured 2 – 3 cm caudal to the
inguinal ligament to ensure the vein is cannulated in the area of
the thigh. A catheter at least 15 cm in length can then be inserted
into the femoral vein by directing the tip toward the vein at a 45 °
angle to the skin. Once in the vein, the angle of the catheter may
be placed more parallel to the skin surface in order to align with
the lumen of the vessel.
The advantage of using the femoral vein is its large size and
the absence of risk of pneumothorax; however, cannulation is

generally not recommended for cardiopulmonary resuscitation
or in the presence of bleeding disorders [8] . Complications of
femoral vein cannulation include arterial puncture, hematoma,
bleeding, local infl ammation, malposition of catheters tip, and
thrombosis [61] .
Cephalic v ein
In its course away from the axillary vein, the cephalic vein travels
below the clavipectoral fascia in the deltopectoral groove and
descends down the lateral aspect of the arm [46] . The cephalic
vein is most often used for central venous access via surgical
cutdown.
Specifi c a rterial a ccess s ites
Radial a rtery
The brachial artery divides into the radial and ulnar arteries in
the forearm. The radial artery is a favored site for arterial cannula-
tion due to its superfi cial location medial to the styloid process.
The ulnar artery parallels the radial artery. Together, the radial
and ulnar arteries form anastomosing palmar arches supplying
blood to the hands [46] . Prior to cannulation of the radial artery,
adequacy of collateral circulation must be established. The Allen
clavicle touching the bone itself as needed, pointing toward the
suprasternal notch and parallel to the patient ’ s back. Upon enter-
ing the vein, the bevel is turned to the 3 o ’ clock position to facili-
tate passing the catheter.
Immediate risks of SCV cannulation include pneumothorax,
hemothorax, and catheter misplacement. The most common of
these complications is pneumothorax with an incidence of 1 – 6%.
Pneumothorax is primarily associated with direct subclavian or
jugular vein catheterization. Collin and Clarke [56] reviewed the
occurrence of delayed or late pneumothorax (48 – 72 h) following

central venous catheterization and recommended that postinser-
tion chest radiographs be expiratory and upright. Expiration
results in a decreased volume of air in the lung but not in the
pleural space thus magnifying the radiographic appearance of the
pneumothorax [57] . Finally, repeat or delayed chest radiographs
are indicated following catheterizations requiring multiple
attempts, persistent (pleuritic or back) pain and respiratory
symptoms. The standard treatment for pneumothorax has tradi-
tionally consisted of placement of a thoracostomy tube. However
in an investigation by Laronga [58] , pneumothorax was managed
by observation alone and/or the insertion of a pigtail catheter (8.5
French) with a Heimlich valve in the outpatient setting. Also, in
spontaneous breathing patients who have developed a small
pneumothorax, the use of 100% oxygen therapy for 60 minutes
may denitrogenate and attenuate the pneumothorax, thus avert-
ing chest tube insertion.
Hemothorax is an infrequent complication of direct SCV cath-
eterization. Because intrathoracic vascular structures are inacces-
sible for direct compression, subclavian and, to a lesser degree,
IJV direct venous catheterization are contraindicated in patients
with a coagulopathy.
A common location for misplacement of the catheter is in the
ipsilateral IJV. Misplacement is most often detected by radio-
graphic studies. Another technique has been described using the
IJV occlusion test [59] . The occlusion test is performed by apply-
Figure 10.6 Landmarks for subclavian vein cannulation. Using the clavicle, the
subclavian vein is divided into thirds. The junction of the middle and medial third
identifi es the location for needle insertion.
Chapter 10
160

ARTERY
VEIN
B
C
A
Figure 10.7 Estimating femoral vein location. When the femoral arterial
pulsations cannot be appreciated, the location of the femoral vein can be
estimated. (a) Draw a line from the anterior superior iliac crest to the public
tubercle and (b) divide into equal thirds. The junction of the medial and middle
segment approximates the femoral artery and the vein will lie 2 – 3 cm more
medial (c).
indicates an incomplete or occluded ulnar arch. Failure to regain
normal color promptly is presumptive evidence of inadequate
collateral fl ow, and the radial artery should not be cannulated. In
performing this test, care is taken not to hyperextend the wrist,
which could falsely compromise ulnar fl ow.
Once adequate collateral circulation has been determined,
preparation for cannulation of the radial artery can be under-
taken. The wrist is dorsifl exed slightly to optimize exposure of the
artery. This is best accomplished by use of an arm board and
placement of a small gauze roll beneath the dorsal surface of the
wrist, with tape placed across the patient ’ s palm and upper
forearm. When taping the upper forearm, care is taken not to
constrict blood fl ow. Alternatively, an assistant may hold the
patient ’ s arm in place, but access to the puncture site is often
obstructed in so doing. Once positioned, the area is prepped and
anesthetized as described previously. We prefer using a 20 – 22 -
gauge Angiocath. The needle is advanced at a 30 ° angle to the
artery until a fl ash of blood appears in the hub. If using the direct
puncture technique, the angle of the needle is then slightly

lowered and the catheter advanced while holding the needle
stable. This can often be facilitated by rotating the catheter itself
backward and forward, in a drilling motion. If the catheter fails
to advance easily, the operator should avoid trying to force the
catheter because of the risk of traumatic pseudoaneurysm. Often,
both walls of the vessel will have been punctured and the catheter
will lie posterior to the vessel. If the catheter has been advanced
beyond the tip of the metal needle do not advance the needle
farther because of the risk of damage to the catheter. Instead,
completely remove the needle and then slowly withdraw the cath-
eter until pulsatile fl ow is established. At that moment, one can
gently reattempt to advance the catheter or pass a 25 - gauge vas-
cular wire through the catheter, followed by advancement over
the wire. If neither of these maneuvers is met with success, the
catheter should be removed and discarded. The procedure is then
repeated with a new needle and catheter.
If the Seldinger technique (or a modifi cation thereof) is used,
the needle is advanced until a fl ash of blood is observed in the
hub, after which the guidewire is advanced through the needle
until it is 2 – 3 cm into the artery. The catheter can then be
advanced over both guidewire and needle, or the needle can be
removed and the catheter advanced over just the guidewire. Once
the catheter has been advanced, the guidewire and/or needle are
removed, pulsatile fl ow is established, and the line is secured and
connected.
Rarely, cutdown and direct visualization will be required for
radial artery catheterization. If a cutdown becomes medically
necessary, a 2 - cm transverse incision is made 2 cm proximal to
the wrist fold, and the vessel is located by blunt dissection with
small hemostats. The hemostats should separate the tissue in a

plane parallel to the vessel to minimize vessel trauma. Skin hooks
are helpful to hold the incision open. The dissection also is guided
by intermittent palpation to maintain orientation to the vessel.
Once exposed, a 1.0 – 1.5 cm length of vessel should be cleaned
and mobilized, and 2 - 0 or 3 - 0 silk sutures are passed beneath the
test can be used in an attempt to document the adequacy of col-
lateral fl ow. Even so, progressive delayed ischemia of the hand
may occur, requiring amputation [62] . Blanching of the skin may
occur with fl ushing of the catheter and indicate interference with
skin circulation. In cases of radial line - induced ischemia where
perfusion to the hand has been compromised, we have success-
fully used a stellate ganglion block to promote vasodilation and
return perfusion to near necrotic fi ngers.
Allen t est
The Allen test is performed in the following manner.
1 The radial and ulnar arteries are occluded simultaneously.
2 Continuing this occlusion, the patient elevates the hand above
his or her head.
3 He or she repeatedly makes a fi st until the hand blanches.
4 The pressure on the ulnar artery is then released.
The palm should regain its normal color within 6 seconds.
Delay of color from 7 to 15 seconds indicates that ulnar artery
fi lling is slow. Persistent blanching for up to 15 seconds or more
Vascular Access
161
chial plexus may also occur during insertion attempts because of
the vessel ’ s relationship with the three cords of the brachial
plexus. At this point, these cords form a neurovascular bundle
within the axillary sheath. As for brachial cannulation, distal cir-
culation should be checked regularly following axillary arterial

line insertion.
Dorsalis p edis a rtery
The dorsalis pedis artery is located on the dorsal aspect of the foot
and is usually easily palpated, but may be absent in 12% of the
population. Collateral blood supply is usually good, and ischemia
is uncommon following cannulation of this vessel. Collateral cir-
culation, supplied by the lateral plantar artery, can be assessed by
compression of the dorsalis pedis artery, followed by pressure on
the nail bed of the great toe until it blanches. On release of pres-
sure on the nail bed, color should return within 2 – 3 seconds.
To facilitate cannulation of the dorsalis pedis artery, hold the
patient ’ s foot in a neutral position, and introduce a 20 - or 22 -
gauge needle into the artery at a shallow angle to the skin.
Femoral a rtery
The femoral artery as an extension of the external iliac artery lies
just below the inguinal ligament midway along a line drawn from
the superior iliac spine and symphysis pubis just lateral to the
vein and medial to the nerve. The usual catheters employed range
from 20 to 16 gauge, are 16 cm in length, and are attached to a
10 - mL syringe. The needle is inserted about 2 cm below the ingui-
nal ligament and at a 45 ° angle to the skin. The puncture of the
vessel can often be felt by the operator and is heralded by the
ability to rapidly aspirate bright red blood. Also, a gloved fi nger
placed over the hub of the needle can usually feel the arterial
pulsations. Once the vessel is punctured, the needle is lowered to
an angle between 15 – 30 ° and a J - tipped guidewire is inserted into
the vessel. The needle is removed, and direct pressure is applied
to the insertion site to prevent bleeding or hematoma formation.
The catheter is placed over the guidewire, but it is not advanced
until the distal (external) tip of the guidewire itself has been

secured. Care is also taken to ensure that the wire is straight, as
any kinks will make passage of the catheter diffi cult. A scalpel nick
of the skin may be required for ease of passage of the catheter
through the skin. Once the catheter is in place, the wire is removed
and the catheter connected and secured.
A complication peculiar to femoral vessel cannulation is punc-
ture of the back wall of the vessel above the inguinal ligament.
The resulting hemorrhage may dissect into the retroperitoneal
space masking a hemorrhage of up to several liters. Because of
the large size of the femoral artery, vein and the catheters used in
these vessels, the chances of an AV fi stula is higher than with
smaller vessels, especially if both vessels have been penetrated
during a single insertion. Similarly, the larger puncture site makes
bleeding at the time of line removal an issue. Under these circum-
stances, pressure should be applied to the femoral site for 10 – 20
minutes following catheter removal.
vessel with a right - angle clamp. To assist catheter insertion, one
approach is to place one suture proximal and one distal to the
site of vessel puncture. The distal suture can be used to elevate
the vessel for direct visual puncture. If vessel puncture is not
initially successful, traction on the proximal suture will stop the
bleeding, providing visualization of the puncture site and thus
allowing the catheter to be inserted without the necessity of
another puncture. Once catheterized, both sutures are removed
(not tied) and the skin is closed. Pressure should be maintained
on the cutdown site for 5 or 10 minutes to prevent potential
hematoma formation.
Brachial a rtery
The brachial artery is the continuation of the axillary artery.
Collateral circulation is supplied by the ulnar collateral artery.

This artery is best isolated just above the elbow crease medial to
the biceps tendon. A 20 - gauge, 2 - inch catheter is inserted at a 30 °
angle to the skin until blood appears in the hub. The vessel is
cannulated by either the direct, modifi ed, or classic Seldinger
technique. Use of an arm board prevents fl exion at the elbow and
kinking of the catheter.
Use of the brachial artery entails greater risks than use of the
radial artery. These risks include, but are not limited to, the fol-
lowing: (i) adequacy of collateral circulation is much more dif-
fi cult to ensure; (ii) embolization could occlude either of the
major arterial supplies to the hand; and (iii) bleeding in the area
of the median nerve may result in neuropathy and Volkmann ’ s
contracture. If bleeding does occur, a fasciotomy may be surgi-
cally necessary [63] . Cannulation of the brachial artery should
not be attempted in patients with disorders of hemostasis.
Axillary a rtery
The axillary artery is a continuation of the subclavian artery. It
enters the axilla from under the teres major and lies in the proxi-
mal groove between the biceps and triceps muscles medially in
the arm. This artery is almost as large as the femoral artery and
has signifi cant collateral fl ow. As such, axillary artery thrombosis
does not lead to distal ischemia. Since the right axillary artery
arises from the right brachiocephalic trunk, which is itself in
direct communication with the common carotid artery, air, clot,
or particulate matter may embolize the brain during fl ushing.
Thus, it may be safer to use the left axillary artery.
For cannulation, the patient can be positioned either with the
palm of the hand beneath the occipital portion of the head or
with the arm extended and externally rotated. After the vessel is
located by palpation, an 18 – 20 - gauge catheter, measuring at least

5 cm, is inserted into the artery until pulsatile blood is observed
in the hub. The angle of insertion should initially be at about a
30 ° angle to the skin, and once blood return is noted, the angle
is lowered for direct advancement or guidewire insertion. Because
of the close proximity of the axillary artery and the brachial
plexus, hematoma formation in this area could result in nerve
compression. Additionally, direct injury to the cords of the bra-
Chapter 10
162
line in detecting CRBSI, while quantitative blood cultures are
more diffi cult and expensive to perform and could be reserved as
a confi rmatory test when needed. The endoluminal brush seems
best reserved for instances where blood cannot be withdrawn
from the catheter [66,67] .
Catheter removal is also generally recommended in catheter-
ized patients whose presumed catheter - unrelated infections fail
to rapidly improve with appropriate treatment. Others have
investigated the effi cacy of thrombolytic therapy in treating cath-
eter colonization or infection [68] .
The Centers for Disease Contol (CDC) have issued guidelines
intended to minimize and monitor CRI [16] . These guidelines
include, but are not limited to, the following:
• selection of insertion site (subclavian versus femoral)
• strict adherence to aseptic technique at the time of both inser-
tion and dressing change
• changing gauze dressings every 2 days
• changing transparent dressings every 7 days
• not routinely replacing catheters or guidewires with the intent
of preventing infection
• creating “ catheter teams ” .

It is recommended that each patient care area that utilizes
central catheters maintain a surveillance system whereby infec-
tion is documented by specifi cally using number of CRBSIs per
1000 catheter - days. Documenting infection in this manner can
help facilitate interpretation of outcomes between patient care
units. In previous studies, antimicrobial/antiseptic impregnated
catheters were associated with a reduction in CRBSI [69 – 72] .
However, in its latest recommendation the CDC suggests limiting
the use of antimicrobial/antiseptic impregnated catheters to areas
of the hospital with unacceptably high CRBSIs rates (in spite of
implanting appropriate measures) or to patients expected to have
the catheter in place for longer than 5 days. The National
Nosocomial Infection Surveillance System (NNISS) compiles
hospital data to issue benchmarks for CRBSI rates and these data
can be used for comparisons. Though a specifi c obstetric category
is not tracked by the NNISS, data could be extrapolated from
Surgical and Medical Teaching categories with pooled mean
infections/1000 catheter - days of 5.3.
Creating a surveillance system, standardizing catheter - related
education and creating teams vested in catheter care cannot be
emphasized enough. Frankel et al. [73] clearly demonstrated the
importance of such measures in decreasing the CRBSI in their
unit from 11 (well above national benchmarks) to 1.7 per 1000
catheter days by combining corporate performance improvement
methodologies, changes in operating procedures, feedback and
reviews.
Conclusion
Short - and long - term central venous access is a vital tool in
women ’ s healthcare. The proper and safe use of central catheters
requires knowledge of indication, meticulous sterile technique,

Catheter - r elated i nfection
Catheter - related infections (CRIs) include exit - site and tunnel
infections, catheter - associated bacteremia or sepsis, suppurative
thrombophlebitis, endocarditis, and clavicular osteomyelitis. The
exact incidence for catheter - related bloodstream infections
(CRBSIs) is diffi cult to determine due to a number of factors.
However, it is estimated that 80 000 cases occur annually in inten-
sive care units alone; and, of these, there is a potential mortality
rate of 35% [16] . Factors contributing to CRI include type of
catheter and catheter material, number of insertion attempts,
duration, location, type of dressing, experience of personnel,
indication for catheter insertion and virulence of the infecting
organism [16,64,65] . Upper extremity locations for catheter
insertions are less often associated with infection compared with
those inserted in the lower extremities. Coagulase - negative
Staphylococcus , followed by Enterococcus and Staphlococcus
aureus are the organisms most commonly associated with
catheter - related bloodstream infection. Unfortunately, antibiotic
resistance is also more frequently encountered with these
organisms.
Catheter - related bloodstream infection is suspected clinically
when signs of infection at the exit site are seen (e.g. erythema,
tenderness, purulent drainage) or systemic signs of infection
(e.g. fever, rigors, fl uid sequestration, rising peripheral WBC
count) are noted, particularly in patients lacking another likely
source of infection. Historically, when signs of catheter - related
bloodstream infection became manifest, the catheter was removed
for culture of the catheter tip. Unfortunately, many catheter
tip cultures returned as negative and only a small percentage
of infections could actually be linked to the catheter. Catheter

lumen colonization is a prerequisite to CRBSI. This knowledge
has prompted the development of in situ techniques to
determine catheter colonization and possibly avoid catheter
removal.
Such techniques include the following.
1 S u p e r fi cial, semiquantitative culture from the skin at the exit
site and the catheter hub. A dry cotton swab is used to sample a
3 - cm area around the exit site, and another dry cotton swab is
introduced into the catheter hub.
2 Paired quantitative blood cultures from the peripheral blood
and catheter. Peripheral blood (10 mL) is obtained and distrib-
uted into aerobic and anerobic culture media followed by blood
from the catheter (10 mL from each lumen) which is likewise
distributed.
3 Differential time to positivity of simultaneous samples from
peripheral blood and the catheter hub. Again, 10 mL is obtained,
simultaneously from the peripheral blood and catheter lumen.
4 Endoluminal brushing of the catheter. This technique was
described as useful when blood could not be obtained from the
catheter.
The superfi cial semiquantitative and differential time to posi-
tivity are sensitive and specifi c enough to be considered as fi rst
Vascular Access
163
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complications, maintenance, and surveillance.
Acknowledgement
Special thanks to Maria D. Koutrouvelis for photography.
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43 Barclay GR , Allen K , Pennington CR . Tissue plasminogen activator
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47 Ho CM , Lui PW . Bilateral hydrothorax caused by left external jugular
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48 Macdonald S , Watt AJ , McNally D , Edwards RD , Moss JG.
Comparison of technical success and outcome of tunneled catheters
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49 Karakitsos D , Labropoulos N , DeGroot E et al. Real - time ultrasound -
guided catheterization of the internal jugular vein: a prospective com-

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50 DeMatteis J. Brachial plexus injury caused by internal jugular can-
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51 Seneff MG. Central venous catheterization. A comprehensive review .
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53 Segura - Vasi A , Suelto M , Boudreaux A. External jugular vein can-
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165
Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade,
M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd.
11
Blood Component Replacement

David A. Sacks
Department of Research, Southern California Permanente Medical Group, Pasadena, CA, USA
Introduction
Transfusion of blood components is a potentially life - saving pro-
cedure. Although meticulous care is taken in the selection of
blood donors, processing, storage, and transfusion of blood prod-
ucts, serious transfusion - related complications may ensue. It is
incumbent on the physician to be sure that a blood product is
indicated, and that standard transfusion practices and precau-
tions are observed [1] . This chapter is intended as an aid to
understanding the preparation of, indications for, and potential
complications of blood components for obstetric critical care.
Blood d onation, c ollection, and s torage
Blood d onation
The prerequisites for blood donors are stringent, and require that
the potential donor be in good health and not have been exposed
to drugs which may have a deleterious effect on blood compo-
nents (e.g. aspirin on platelet function). The donor must also be
free of bloodborne bacterial, viral, and protozoal agents as well
as not having had sexual contact with those who may be infected
with these agents. A partial list of the American Association of
Blood Banks ’ (AABB) requirements for donors is found in Table
11.1 . Of note is the response to the 2003 FDA requirement for
screening blood for West Nile virus. The bones of contention are
that bloodborne West Nile viral infections are infrequent (0.44
per 10 000 donations in 2004 [2] ), are of low infectious potential,
and require costly testing. A strategy of testing “ minipooled ”
blood samples from several donors during the half of the year
when the incidence of infection is low, with individual testing
reserved for those contributing to a positive minipool, has been

proposed. The proposal includes individual testing during an
outbreak [3] .
Because the recipient is the same person as the donor, the
requirements for an autologous donor are less stringent than
those for allogeneic donors. Requirements include a hemoglobin
of only 11 g/dL, deferral only when there is a possibility of bacte-
remia in the donor, and that the collection be performed no fewer
than 72 hours before the anticipated transfusion [1] .
Apheresis is a procedure wherein whole blood is withdrawn
from a donor, a liquid (e.g. plasma) or solid (e.g. platelets)
portion is retained, and the remainder of the blood reinfused. The
time interval between donations is shorter for apheresis donors
than for donors of whole blood. For example, donors of platelets
may undergo apheresis up to twice a week, but no more than 24
times a year [1] . However, the other requirements for allogeneic
donors also apply to apheresis donors (Table 11.1 ).
Blood c ollection and i mmediate s torage
A unit of blood should be collected with a minimum of trauma
and over a short time period (4 – 10 minutes) to decrease the
likelihood of activation of coagulation factors. Each collection
bag usually contains an average of 450 ± 45 mL of whole blood
plus 63 mL of anticoagulant/preservative. The purpose of the
anticoagulant/preservative is to prevent clotting and to maintain
cell viability and function. Two commonly used storage solutions
are CPD (citrate - phosphate - dextrose) and CP2D. The citrate
chelates calcium, and prevents activation of the calcium - depen-
dent steps of the coagulation process. Dextrose serves as a sub-
strate for red cell glycolysis, while phosphate buffers lactic acid
produced by metabolism. Storage of collected blood at 1 – 6 ° C
slows glycolysis. If, however, platelets are to be separated from

the whole blood the latter must be fi rst cooled to no lower than
20 ° C and the platelets separated within 4 hours of phlebotomy.
The United States Food and Drug Administration (FDA) approves
storage of blood products containing red cells (RBCs) at 1 – 6 ° CC
in CPD and CP2D for 21 days. The addition of adenine to the
storage solution (e.g. in CPDA - 1) to support RBC synthesis of
ATP allows the blood to be stored for 35 days. Within 72 hours
of collection and following removal of plasma (see below) 100 mL
of an additive solution containing such substances as saline,
Chapter 11
166
adenine, mannitol, and dextrose to support red cell survival may
be added from a satellite bag to the remaining red cells, thus
prolonging the shelf life of the unit to 42 days [4] .
Separation of w hole b lood into c omponents
The term “ blood component therapy ” refers to the use of specifi c
components of whole blood for a specifi c patient ’ s needs. By
Age Minimum 17 years
Volume of blood
collected
Maximum 10.5 mL/kg of donor weight
Donation interval 8 weeks
Blood pressure
≤ 180 mmHg systolic
≤ 100 mmHg diastolic
Pulse
50 – 100 BPM non - athletic; < 50 BPM in a healthy athlete
Temperature
≤ 37.5 ° C
Hemoglobin/hematocrit

≥ 12.5 g/dL/ ≥ 38%
Drugs taken Aspirin: defer for 36 hours beyond last ingestion
Isotretinoin: defer for one month after last dose
Bovine insulin from the UK: defer indefi nitely
Medical history Family history of Creutzfeldt – Jakob disease: indefi nite deferral
Pregnancy: Defer for 6 weeks after pregnancy termination
Receipt of blood
components
Defer for 12 months

Infectious disease

Indefi nite deferral
History of viral hepatitis ≥ age 11
HBsAg [+]
Repeated reactive test for anti - HBc antibody
Present or past clinical or laboratory test for HIV, HCV, HTLV, or syphilis
History of babesiosis or Chagas ’ disease
Stigmata of parenteral drug use
12 - month deferral
from time of:
Sexual contact with an HIV - infected individual or one at high risk for HIV infection
Sexual contact with an individual who has any form of clinically active viral hepatitis
Sexual contact with an individual who is HBsAg [+]
Sexual contact with an HCV [+] individual who has had clinical hepatitis within the
past 12 months
History of, or completion of therapy for syphilis or gonorrhea
Malaria Diagnosis of, or symptoms of malaria after having lived in an
endemic area: defer for 3 years after becoming asymptomatic
Having lived in an endemic area for ≥ 5 years: defer for 3 years after departing the area

Having traveled to an endemic area: defer for 12 months after departing the area
West Nile virus Defer per FDA recommendations
Table 11.1 Selected requirements for allogeneic
blood donors, per AABB standards [1] .
using blood components, 1 donor unit can benefi t several
patients, as well as allowing conservation of unused components
for future use. In addition, components may be used to manu-
facture such derivatives as individual coagulation factors and
immune globulin. To maintain sterility, and thus shelf life, a unit
of blood to be divided into components is collected into a primary
bag to which up to three satellite bags are attached. Because red
Blood Component Replacement
167
Red b lood c ells l eukocyte r educed
A unit of RBCs contains 1 – 3 × 1 0
9
leukocytes. A unit of RBCs
leukocyte reduced must contain no more than 5 × 1 0
6
leukocytes
per unit and must contain 85% of the RBCs in the original unit
[1] . Leukocytes may be removed from whole blood following
addition of the anticoagulant/preservative by in - line fi ltration. By
centrifugation of the fi ltered product both leukocyte - reduced
RBCs and plasma may be retained. Alternatively, RBCs may be
fi ltered after separation from plasma in the blood collection
center or in the laboratory. Prestorage and laboratory leukocyte
reduction is preferable to in - line leukocyte reduction at the time
of transfusion. During storage leukocytes fragment, degranulate,
or die, potentially releasing substances that result in febrile non -

hemolytic transfusion reactions [8] . In addition, removal of leu-
kocytes within 24 hours of phlebotomy may reduce the risk of
bacterial contamination of the RBC product [9] . Antibodies to
leukocyte antigens are responsible for febrile non - hemolytic
transfusion reactions. Thus transfusion of RBCs leukocyte
reduced is indicated for patients who have had recurrent febrile
non - hemolytic transfusion reactions. Others who may benefi t
from receiving RBCs leukocyte reduced are those who are likely
to have been previously exposed to leukocyte antigens. Included
among the latter are women who have had several pregnancies
and those who have received or who anticipate receiving several
transfusions [10] . In addition, this product has been found to be
as safe as cytomegalovirus - seronegative blood in preventing the
transmission of this bloodborne viral pathogen [11] .
Red b lood c ells w ashed
Washing red cells in 1 – 2 L of normal saline removes 99% of
plasma proteins as well as electrolytes, some granulocytes, plate-
lets, and cellular debris. Approximately 20% of the red cell
volume is lost during washing. Washed cells are usually resus-
pended in normal saline to a hematocrit of 70 – 80%, in aliquots
of about 180 mL. Cells may be obtained from banked blood at
any time during the shelf life of the unit. Because washing takes
place in an open system, and because washed cells are separated
from their preservative solution, they must be used within 24
hours of washing to prevent bacterial contamination and main-
tain cell viability. Red cells washed are indicated for IgA - defi cient
recipients at risk for anaphylaxis due to exposure to IgA antibod-
ies in donor plasma. They are not a substitute for red cells leuko-
cyte depleted [5] .
Red b lood c ells f rozen; r ed b lood c ells d eglycerolized

Long - term storage of frozen red cells may be indicated for those
individuals who have rare blood types and for some autologous
donors. In the process of cooling extracellular water freezes
before intracellular water. The resultant osmotic egress of intra-
cellular water results in red cell dehydration. To prevent this,
glycerol, a cryoprotective agent to which the red cell membranes
are permeable, is added to create an intracellular osmotic force
preventing cellular dehydration. In addition, a high concentra-
tion (e.g. 40%) of glycerol prevents formation of ice crystals
cells, plasma, and platelets have different specifi c gravities, they
are separated and initially stored in these satellite bags by dif-
ferential centrifugation [4] . While a detailed description of all
available blood products is beyond the scope of this chapter, a
brief description of those products used for obstetric critical care
follows. For greater detail, interested readers are referred to
appropriate texts [4,5] .
Whole b lood and c omponents: d escription
and i ndications
Whole b lood
A unit of whole blood has a volume of approximately 500 mL and
an additional 70 mL of anticoagulant/preservative. The hemato-
crit of the unit is from 36 to 44%. At the time of collection a unit
of whole blood contains red cells, granulocytes, platelets, and
plasma. After 24 hours of storage few platelets and granulocytes
remain. Levels of labile coagulation factors V and VIII diminish
progressively with storage, while stable clotting factors II, VII, IX,
X, and fi brinogen are maintained. In addition, 2,3 - diphosphogly-
ceric acid (2,3 - DPG), an intracellular molecule that promotes
dissociation between hemoglobin and oxygen, decreases with
storage to a concentration of zero after 2 weeks [6] . Functionally,

a decrease in 2,3 - DPG in stored red cells results in less oxygen
release to peripheral tissues than is released by fresh cells.
However, 2,3 - DPG is completely restored in blood 24 hours after
transfusion [7] . Because whole blood provides both oxygen car-
riage and volume expansion, current indications for whole blood
are limited to use for patients at risk for hemorrhagic shock, e.g.
those who have lost 25% of their blood volume and who have
persistent blood loss [5] . While an advantage of whole blood is
the limited number of donors to whom the recipient is exposed,
whole blood does not provide platelets and labile clotting factors.
A unit of whole blood raises the hematocrit by 3 – 4%. Because of
concerns for fl uid overload, whole blood should not be used for
normovolemic patients.
Red b lood c ells ( RBC s )
RBCs are prepared by centrifuging whole blood followed by sepa-
ration of the RBCs from plasma. A unit of RBCs collected in CPD
or CPDA - 1 has a hematocrit of 65 – 80%. Because of the greater
volume of anticoagulant/preservative used, a unit stored in addi-
tive solution has a hematocrit of 55 – 65%. The indication for RBC
transfusion is a need for oxygen carriage. Because a unit of RBCs
contains the same number of red cells as does a unit of whole
blood, it, too, will raise the hematocrit by about 3 – 4%.
Recently the collection of RBCs by apheresis has gained in
popularity, partially in response to a shrinking donor base.
Apheresis allows for the collection of 2 units of red cells at the
same time. This has the benefi t of exposing the recipient to fewer
donors and to a lower transfusion risk while providing potential
cost savings. However, the interval between red cell donations by
apheresis lengthens to 16 weeks [1] .
Chapter 11

168
for febrile non - hemolytic transfusion reactions. Controversy
exists regarding whether of not their use is protective against
platelet refractoriness [13] . Platelets leukocyte reduced are,
however, useful in reducing transmission of CMV [14] .
Fresh f rozen p lasma and t hawed p lasma
A unit of fresh frozen plasma (FFP) is prepared by fi rst separating
plasma from red cells in whole blood within 8 hours of phle-
botomy. It may be banked for 1 year if then frozen to − 18 ° C, and
for 7 years frozen at − 65 ° C [1] . Plasma may also be obtained by
apheresis. As with apheresed red cells and platelets, apheresis
offers the opportunity of collecting 2 units of plasma at the same
collection from the same donor. A unit of FFP contains all clot-
ting factors, including labile factors V and VIII. Likely the most
common indication for FFP in obstetrics is in the face of sudden
massive decrease of clotting factors, such as is seen in dissemi-
nated intravascular coagulation (DIC) and the dilutional coagu-
lopathy accompanying volume replacement for hemorrhage.
Once stabilized, the patient ’ s need for further FFP transfusion
should be based on laboratory testing, as clinical bleeding due to
clotting factor defi ciency is rarely seen if the International
Normalized Ratio (INR) is below 1.6 for activated partial throm-
boplastin time and prothrombin time. An INR of 1.6 or greater
indicates factor concentrations of 30% or lower [15] . FFP is also
indicated for patients who have congenital factor defi ciencies for
which specifi c factor concentrates are not available, such as
factors II, V, X, and XI [4,5] . While the volume of plasma trans-
fused is a function of clinical response, 3 – 6 units will raise the
concentration of coagulation factors in a factor - depleted patient
by 20% [5] . While compatibility testing is not necessary, trans-

fused plasma should be ABO compatible with recipient ’ s blood
[1] . Once thawed to 30 – 37 ° C it should be either immediately
transfused or stored for no more than 24 hours at 1 – 6 ° C. From
the time of thawing to 24 hours thereafter this product is renamed
“ FFP thawed ” . “ Thawed plasma ” is thawed FFP stored at 1 – 6 ° C
days beyond the initial 24 hours of thawing and may be trans-
fused for up to 5 days after thawing. While this product is defi -
cient in factor VIII, it retains the minimum factor V activity
(35%) required for coagulation [5] .
Cryoprecipitated a ntihemophilic f actor ( CRYO )
A unit of CRYO is prepared by thawing a unit of FFP to 1 – 6 ° C.
The supernatant plasma is then removed. The remaining insolu-
ble portion (the precipitate) along with about 15 mL of plasma is
refrozen to − 18 ° C and may be stored for up to 1 year. A unit of
CRYO contains concentrated factor VIII:C (procoagulant), factor
VIII:vWF (von Willebrand ’ s factor), factor XIII, and fi brinogen.
Its major indication in obstetrics is for the replacement of con-
centrated fi brinogen in the presence of DIC. In addition, CRYO
to which thrombin has been added (to convert the fi brinogen in
CRYO to fi brin) has been found to form an effective plug in vitro
for punctured amniotic membranes [16] .
which may destroy cell membranes [4] . A unit of glycerolized red
cells may be stored at − 65 ° C for up to 10 years. Ordinarily red
cells are frozen within 6 days of collection. However, cells stored
at 1 – 6 ° C in CPD or CPDA - 1 may have their ATP and 2,3 - DPG
restored by adding an FDA - approved solution of pyruvate,
inosine, phosphate, and adenine within 3 days of expiration.
These rejuvenated cells may then be glycerolized and frozen [1,4] .
To prepare frozen cells for use they are washed in dextrose and
saline solutions of progressively decreasing osmolarity, to maxi-

mize removal of glycerol and to minimize cell damage and loss.
At least 80% of cells must be recovered following deglycerolyza-
tion. Red cells deglycerolized in an open system must be trans-
fused within 24 hours. Those deglycerolized in a closed system
may be stored at 1 – 6 ° C for up to 14 days [1,4,5] .
Platelets
Random donor platelets are separated from whole blood that has
not been cooled below 20 ° C within 4 hours of phlebotomy.
Following centrifugation the platelets are resuspended in 50 –
70 mL of plasma, an amount necessary to maintain stable clotting
factors, and a pH of at least 6.2. To maintain viability and func-
tion they are stored at temperatures of 20 – 24 ° C with constant
gentle agitation for up to 5 days. Platelets may also be obtained
by apheresis. A unit of random donor platelets contains 5.5 × 1 0
10

platelets. A unit obtained by apheresis contains 3 × 1 0
10
platelets,
or the equivalent of 5 – 6 random donor units. Platelet transfu-
sions are indicated for bleeding associated with thrombocytope-
nia (platelet count less than 50 000/ µ L). They may be indicated
in the face of thrombocytopenia associated with platelet destruc-
tion (e.g. autoimmune thrombocytopenia, disseminated intra-
vascular coagulation) accompanied by bleeding. One unit of
random donor platelets raises the platelet count by 5000, while
an apheresed unit raises the count by 30 – 60 000. Because they
express ABO antigens on their surface and because donor plasma
may contain anti - A or - B antibodies, platelets ideally should be
ABO - compatible with recipients ’ blood. Because a unit of plate-

lets may contain red blood cell fragments, Rh - negative recipients
should receive platelets from Rh - negative donors.
As a rule, apheresed platelets are preferable to random - donor
platelets. Transfusing the same volume of platelets from a single
donor as would be obtained from fi ve or six donors limits
the recipients ’ potential exposure to bloodborne pathogens
and to alloimmunization. A specifi c indication for apheresed
platelets is evidence of platelet refractoriness. This entity is
defi ned by a failure to raise the recipient ’ s platelet count by a
calculated minimum number [12] , and is usually due to recipient
antibodies to Class I HLA antigens on donor platelets. These
antigens are integral proteins within the platelet membranes.
Apheresed HLA - matched platelets are indicated for such recipi-
ents [4,5] .
Both random donor and apheresed platelets may be collected
using leukocyte reduction fi lters. Platelets leukocyte reduced are
indicated (as are red cells leukocyte reduced) for patients at risk