BLOOD

AND

BLOOD COMPONENT THERAPY

DR R K BISHNOI

BLOOD TRANSFUSION: HISTORY

Pope Innocent VIII

FIRST HISTORICAL ATTEMPT Of blood transfusion was in 1492. Pope Innocent VIII sank into a coma.

The blood of three boys was infused into the dying pontiff (through the mouth).

The boys were ten years old, and had been promised a ducat(kind of gold coin) each.

However, not only did the pope die, but so did the

three children.

HISTORY

China, 1000 BC The soul was contained in the blood.

Egyptians bathed in blood for their health.

Pliny and Celsus describe Romans drinking the blood of fallen gladiators to gain strength and vitality and to cure epilepsy.

Taurobolium, the practice of bathing in blood as it cascaded from a sacrificial bull, was practiced by the Romans.

RICHARD LOWER

1665, THE FIRST AUTHENTIC BLOOD TRANSFUSION (ANIMAL TO ANIMAL).

HE KEPT EXSANGUINATED DOGS ALIVE BY CONNECTING THE CAROTID ARTERY→JUGULAR VEIN OF THE RECIPIENT DOG WITH A QUILL.

•1665 conducted by Richard Lower, an Oxford physician started as dog-to-dog experiments and proceeded to animal-to-human over the next two years.

•Lower (1665)

FIRST BLOOD TRANSFUSION

Animal to Human Transfusion

Early lamb blood transfusion

WHAT IS NEW SCENARIO Transfusion practice has come a long way

from animal to human transfusion to today’s practice where we have artificial blood coming out of shelf .

Though it is expensive but at present we can select the component desired by patient according to his illness.

FOR BETTER MANAGEMENT WE SHOULD STRICTLY MAINTAIN

Proper selection of donor.

Screening of donor.

Compatibility testing.

Rational use of blood component therapy.

Transfusion and monitoring

DONOR SELECTION Criteria for donation: a healthy person with

Age:>18 yrs <60 yrs.

weight:>48kg but for

whole blood for component preparation >60kg

Hb>12.5 gm/dl

WHO CAN NOT DONATEo The person is unhealthy and thus cannot tolerate

the hemodynamic stress. Hematocrit value < 34 A blood bank or a camp organized by a blood bank is

not available

Suffering from any of the following:HepatitisB,C, HIV/AIDS, syphilis, Malaria.(MALARIA- the blood is not to be taken for six

months.)

WHO CAN NOT DONATEH/O of Jaundice during the past one year.

H/O major surgery in past 6 months.

Patient is currently suffering from a malignant disease, active TB. or epilepsy.

Women when pregnant or lactating.

Professional donors.

WHY VOLUNTARY DONATION?

Only half of the requirements of blood in India is generated by voluntary donation (30 Lac

units are donated against the 60 Lac unit requirement).

As per the Supreme Court ruling, since January 01, 1998 blood shall be accepted only from

voluntary donors. No blood bank can utilize professional (paid)

donors for collection of blood.

Indian Journal for the Practising Doctor

• Banning the professional donors in

blood donation has good impact

though resulting in "scarcity of blood" and

encouraging grey areas in marketing in private Blood Banks

NO REPLACEMENT REQUIRED FOR

Thalessemic Pts.

HIV positive pts.

Destitute pts. like shishugrah.

Hemophilic pts.

HEALTH EDUCATION ASPECTS OF BLOOD DONATION:

Human blood has no natural or synthetic substitute, so it has to be donated by other human beings.

A healthy adult can donate blood every 3-4 months. Every male has a surplus of 27ml /Kg and

every female 16ml /Kg in excess of the normal requirements.

Thus every person can donate @ 8ml/kg body weight. (8x45=360ml) at one sitting

every 3 months.

HEALTH EDUCATION ASPECTS OF BLOOD DONATION:

Blood donation- no discomfort or weakness during or after donation.

Replacement starts immediately after donation, and is complete within 12 weeks.

No chances of acquiring infection from donating blood as the entire procedure is sterile.

Voluntarily donated blood is healthy for recipients.

Professional donors are themselves unhealthy.

PRACTICE POINT:

If weight of the person is 60 kg, his total blood volume (80x60) will equal 4800 ml.

A 20% volume loss (960 ml), can be

tolerated and needs only plasma expanders.

However, pts with 30% volume loss (1440 ml): require blood transfusion.

Indian Journal for the Practising Doctor

SENDING THE REQUISITION FORM AND BLOOD SAMPLE OF PATIENT

Correct identification of the pt. Sample into the type of sample tube required by the

blood bank. Label the sample tube clearly and accurately

at the pt’s bedside the moment sample is being taken.

Labeling includes:patient’s name.Hospital registration no.Patient’s ward.Date.Signature of person taking sample.

These should match with medical records.

PRE-TRANSFUSION TESTSSerological tests:- Blood grouping-ABO

- Irregular antibody screening - type and cross-match.

o Transfusion transmitted disease tests: HIV

HBV HCV VDRL MP NAT

WHAT IS NAT?

Nucleic Acid Amplification Test is highly sensitive test for detection of the virus.

This is done by amplification of the genetic materials by over a billion folds.

NAT is a direct test for presence of Viral Genetic material in the blood.

CLOSING THE WINDOW ON VIRAL INFECTION

Detection of HIV-1

Detection of HCV

Detection of HBV

11 days 22 days

23 days 98 days

34 days 56 days

BLOOD TYPING AND SCREENING

To ensure that a person who needs a transfusion will receive compatible blood with his or her own; and

That clinically significant antibodies are identified if present.

OBJECTIVES OF B.T & COMPONENT THERAPY

Restoration of blood volumeEnhance the O2 carrying capacity of bloodMaintain Homeostasis – Platelet– Coagulation Factors– Fresh blood– FFP or Appropriate component

BLOOD

Blood is a vital and life saving fluid.

Can neither be manufactured in factories, nor substituted with blood of any other creature.

But Direct transfusion of infected blood

can lead to transmission of various diseases like hepatitis, syphilis, malaria and HIV.

SAFE BLOOD

Blood that is free of transmissible diseases,

Compatible with the recipient.

Stored optimally.

BEFORE TRANSFUSION WE MUST DETERMINE WHAT FOR ANY PROCEDURE

Whether required

How much required

Actual component required

Time of duration of transfusion

Components

Blood-cells products

-whole blood -packed red blood cells -leukocyte-poor (reduced) red cells-washed red blood cells-random-donor platelets concentrates

BLOOD PRODUCTS(1)

•Single-donor platelets concentrates.

•Irradiated blood products (red blood cells and platelets

concentrates)

•Leukocyte (granulocyte) concentrates

BLOOD PRODUCTS(1)

BLOOD PRODUCTS(2)

Plasma products • fresh-frozen plasma (FFP)• cryoprecipitate• factor concentrates (VIII,

IX) • albumin• immune globulins

CELLULAR -PRBC -PLATELETS -GRANULOCYTES

PLASMA -FFP -CRYOPRECIPITATE -FRACTIONETED COMP (FACTOR VIII AND IX)

UNMODIFIED COMPONENTS

MODIFIED PRODUCTS

•IRRADIATED -PRBC

-PLATELETS-GRANULOCYTES

•LEUCOCYTE DEPLETED -PRBC-PLATELETS

•SALINE WASHED -PRBC-PLATELETS

WHICH COMPONENTSFrom one unit of whole blood one can make•PRBC•Platelet pack(random donor)•Fresh plasma•Granulocyte pack•Fresh plasma →frozen at -30°C→FFP•Pooled plasma→ components Cryoprecipitate Albumin Gamma globulins Anti-D globulins Plasma proteins

STORAGE AND SHELF LIFEPRODUCT VOLUME INDICATIONS/

STORAGE

Red Blood Cells (RBC)

SALINE WASHEDPRBC

250 mls red cells100 ml SAGM~ CPD

02 transport

Hct. 75 ± 5%1-6 oC ~ 42 days24hrs once packed.

24 hrs

Platelets  SDP(single donor,apheresis)

Buffy coat derived (4 donors, 1 plasma)

 200-300 ml(NO ALIQUOTES)

300x109platelets/unit

Thrombocytopenia/Dysfunctional Platelets

20-22oC x 5 days

Constant agitator.  

WHOLE BLOOD 450+63 MLS(>60KG)350+49 MLS

BLOOD LOSS1-4˚C35-42 DAYS

PRODUCT VOLUME INDICATIONSTORAGE

Fresh Plasma

(FP) ↓ FFP

100 - 150 ml/unit

100-120 ml/unit in SMS Hosp

1-6°C,35-42days.Hypoproteinemia.

All coagulation factors-20oC x 12 months

Cryoprecipitate

NOT AVAILABLE IN SMS HOSPITAL

10-15ml/unit VWF 80 I.U.VIIIc :80-120 I.U.Fibrinogen > 150 mgXIII-30°C ,1 yr

Albumin

Granulocyte pack(available)

Variable

50 ml/unit

Volume expansion

Room temp

24 hrs.

Solution Purpose Whole blood or Red cell

Storage Period

Additive Concentrations( per 100 ml )

Performances

 CPD Anticoagulant and storage of

Blood

21 days Sodium Citrate (dihydrate)....2.63g Citric Acid (monohydrate)...0.299g

Dextrose (monohydrate).......2.55g

Monobasic Sodium   Biphosphate (monohydrate).0.222g

Prevents coagulant of blood    as Citrate ion chelates           CalciumNutrition source for red cell

Adjusts pH

 CPDA 1 Anticoagulant and storage of Blood

35 days Sodium Citrate (dihydrate).....2.63g Citric Acid (monohydrate)....0.299g

Dextrose (monohydrate).........2.9g

Monobasic Sodium   Biphosphate (monohydrate).0.222gAdenine...........................0.0275g

Prevents coagulant of blood    as Citrate ion chelates Calcium

Nutrition source for red cell

Adjusts pH

Supports to maintain ATP    level in red cells

 SAGM Red cell Preservation

42 days Dextrose (monohydrate)......0.900gSodium Chloride...................0.877g

Adenine...........................0.0169g

D-Mannitol.........................0.525g

Nutrition source for red cellAdjusts osmotic pressure

Supports to maintain ATP    level in red cellsSupports integrity of red cell   membrane (to avoid    haemolysis)

Whole Blood

Contents•RBC’s•WBC’s•Platelets•Plasma•Clotting factors

WHOLE BLOOD Stored at 1-4˚C Shelf life of 35-42 days. First 4-6 hrs -100% of all the components.

Changes with time Platelets fall to less than 1% by 4-48hrs. Labile clotting factors V and VIII also disappear in same

time.• other clotting factors II,VII,IX,X thereafter.• K+ level ↑,ATP level ↓• 2-3DPG and PH ↓ especially after 5-7 days of storage.

RECONSTITUTED WHOLE BLOOD

PRBC suspended in AB Rh-VE plasma used with platelets if required.

10cc/kg body weight of whole blood will raise Hct by 3-5% and Hb by 1 to 1.5 gm%.

STORAGE OF FRESH BLOOD PRODUCTS

Fresh blood products should never be stored in clinical areas.

All products should begin administration within 30 minutes of collection from

blood bank or returned to blood bank for correct monitored storage.

All Fresh blood products need to be administered within four hours of the product bag being spiked.

WHY NOT WHOLE BLOOD AND WHY COMPONENTS?

More than 6 important componentsin each Unit of whole blood.

Each component has a specialized function.

All functions are not deranged in all the patients and so

All the components are not required all the

time.

WHY NOT WHOLE BLOOD AND WHY COMPONENTS?

Blood is always in short supply.

Making components from one unit of whole blood will satisfy the needs of more than one patient from the same unit of blood.

WHY NOT WHOLE BLOOD AND WHY COMPONENTS?

Whole blood will lead to harmful effects: plasma overloadLymphocyte mediated toxicitiesAllosensitization etc.

Some components-effective as component only eg: platelets which are otherwise destroyed in

stored whole blood. Some components-better given as components

eg: clotting factors. Level can be achieved at much higher level or even

100% by giving concentrates of such factors, than by giving whole blood or even FFP.

Indications

Acute loss of whole blood.

Exchange transfusion in infants for hemolytic anemia of the newborn.

ADVANTAGE

All components.

DISADVANTAGE

Side effects due to plasma and lymphocytes as their level remains almost 100% till last date of storage.

Simply wastage of components not required.

BLOOD TRANSFUSION

Attention ： Double Check: Name, Type and Cross-match

Storage Time: Citrate Phosphate Dextrose

Acidic Citrate Dextrose

21D, 35D

Pre-heat

Observation during / after Transfusion ：

BLOOD WARMERS Consider warming red blood cells in the following

circumstances: -Patient's receiving massive transfusion -The hypothermic patient requiring transfusion -Exchange transfusion.

Beigler blood warmers must only be used. Blood should NEVER be warmed via a microwave,

immersion in water or by placing it on heat generating machinery.

Blood Component Preparation“A little goes a long way”

RED CELL TRANSFUSIONS: INDICATIONS AND TRIGGERS

RED BLOOD CELLS - DESCRIPTION:

Whole blood is collected into an anticoagulant then centrifuged to separate the red cells from the plasma.

The plasma is then expressed from the whole blood bag and the remaining red blood cells (RBC) are filtered.

85% of the original RBC volume will remain after filtration.

A typical unit has a volume of 240-340 mL and a hematocrit of 80%.

Plastic Blood Bags and Component Separation

PACKED RED BLOOD CELLS (PRBC)

PRBC contains packed red cells in 22-50% of original plasma.

Has nearly 100%of polymorphonuclear cells and lymphocytes but has less than 10% platelets and clotting factors.

Ideal Hct for PRBC is 70-75%. It should not be too tightly packed.

For newborns while doing exchange transfusion,Hct can be adjusted to 50-55% using additional FFP or albumin.

Indian journal of practical pediatrics

ADVANTAGE Low volume-no circulatory overload.

Less plasma –so less citrate related toxicity.

DISADVANTAGE More viscous-flow with difficulty through pediatric IV lines. Shelf life is 24 hrs, once packed. Significant amount of plasma and leukocytes so Toxicity

related to them:Allergic reactionsNHFTRAllosensitizationGVHD

A SINGLE UNIT of blood is rarely, if at all, is of any benefit to the recipient and carries all the risks associated with blood transfusion.

INDICATIONS:PRBC

Commonest indication:-chronic transfusion dependent anemia:

Thalessemias, Sickle cell disease, Congenital dyserythropoietic anemia, Diamond Blackfan syndrome, Fanconi’s anemia, Aplastic anemia, Chronic renal failure, Cancer pts, Sideroblastic anemia etc.

INDICATIONS

Episodic transfusions for acute hemolysis G6PD deficiency, Malaria, Autoimmune hemolytic anemia, Rarely, if at all, used in nutritional anemia

-severe anemia with impending cardiac failure.

Has associated cardio-respiratory disease. Before surgery.

Indian journal of practical pediatrics

Most oftenly misused as Top-ups in pts with nutritional anemia or before surgery to keep Hb>10gm%

It is counterproductive as it can lead to immunosupression of recipient anddelay in healing.

INDICATIONS IN NEWBORNS

Any cause of bleeding.

Iatrogenic blood loss especially-sick pre-terms

Anemia of prematurity:when baby has poor sucking, apneic spells, poor weight gain, and Hb<7gm%.

Very sick neonates usually have associated sepsis, acidosis, DIC, bleeding, and anemia and will need support with PRBC, platelets and FFP.

•INDICATION FOR TRANSFUSION IN ANEMIC PATIENTS

• Decision to transfuse based on clinical condition rather than a given level of hemoglobin.

• chronic stable anemia - probably unjustifiable if the hemoglobin level is above 7g per 100ml

•Symptomatic anemia(dizziness,weakness, shortness of breath), underlying cardiac, pulmonary, or vascular disease.

CHILDREN AND ADOLESCENTSACUTE LOSS OF >25% CIRCULATING BLOOD VOLUME

HB<8GM/DL IN PERIOPERATIVE PERIOD

HB<13 GM/DL AND SEVERE CARDIOPULMONARY DISEASE

HB<8GM/DL AND SYMPTOMATIC CHRONIC ANEMIA.

HB <8GM/DL AND MARROW FAILURE.

GUIDELINES FOR PAEDIATRIC RED CELL TRANSFUSION(NELSON,S TEXT BOOK)

INFANTS WITHIN FIRST 4 MONTHS OF LIFE

Hb<13g/dl and severe pulmonary disease. -ventilation

Hb<10g/dl and moderate pulmonary disease. high flow oxygen(CPAP)

Hb <13g/dl and severe cardiac disease. (Cyanosis, CCF)

Hb<10 g/dl and major surgery.

Hb<8 g/dl and symptomatic anemia

IRON DEFICIENCY ANEMIA

Rapid hematologic response with iron therapy.

Transfusion indicated only when

anemia is very severe Hb<4gm (nelson)

WITH CHRONIC ANEMIA, Children compensate well and may be asymptomatic

despite low haemoglobin levels. Treated successfully with oral iron alone, even at

haemoglobin levels of <5 g/dl. Factors other than haemoglobin concentration

to be considered in the decision to transfuse RBCs (1)Patient's symptoms, signs, and functional capacities; (2) Presence of cardio-respiratory, vascular, and central

nervous system disease; (3)Cause and anticipated course of the anemia; and

(4) alternative therapies, such as recombinant humanerythropoietin (EPO) therapy, which is known to reduce the need for RBC transfusions and to

improve the overall condition of children.

HEALTHY PREMATURE INFANTS

Physiologic anaemia- no therapy.

Ensure diet of the infant- essential nutrients for normal haematopoiesis, especially folic acid and iron.

Premature infants feeding well and growing normally rarely need transfusion unless iatrogenic blood loss has been significant.

• Healthy premature infants-Hb< 6.5 g/dl.(nelson)

FRESH V/S STORED RBCS

The traditional use of relatively fresh RBCs(<7days of storage)has been halted in

many centers in favour of diminishing donor exposure by using a single unit of RBCs to obtain aliquots for transfusing each infant throughout its permitted duration of storage (currently 42 days).

Neonatologists who insist on transfusing only fresh RBCs generally are fearful of the rise in

the plasma potassium (K') level that occurs in RBC units during extended storage.

After 42 days of storage,plasma K* levels are approximately 50 mEq/L (0.05 mEq/ml) a value that at lst glance, seems alarmingly high.

However, the actual dose of K* transfused in the extracellular fluid is tiny.

THALLASSEMIA PTS A transfusion program generally requires

monthly transfusions, with the pre-transfusion haemoglobin level >9.5 and<10.5 g/dl.

In patients with cardiac disease, higher pre-transfusion haemoglobin levels may be beneficial.

PRECAUTIONS

Pts with chronic transfusion dependent anemia need SPECIAL PRECAUTIONS:

Detailed blood grouping should be done before first blood transfusion-minor blood group incompatibility.

Always use coomb’s negative cross-matched blood

Best is to use washed PRBC and if affordable,WBC filtered PRBC to decrease leuko-contamination.

Meticulous record of pre and post-transfusion Hb should be kept to see for transfusions and suspect hypersplenism.

Chelation should be started once serum ferritin is more than 1000 ng/ml

PRECAUTIONS

Regular check-ups for 1.Plasma borne infections,

2.LFTs3.Serum ferritin levels

o Lastly all these pts should receive hepatitis-B vaccine before their first transfusion.

Patient Donor

A A, O B B, O AB A, B, AB, OO ORh(+) Rh(+), Rh(-) Rh(-) Rh(-)

PATIENT AND DONOR RBC SELECTION BY ABO AND RH TYPE

RED BLOOD CELLS –CONTRAINDICATIONS:

RBC : should not be used:when anemia can be corrected with

specific medications, e.g., iron, B12, folic acid, erythropoietin, etc.

for volume replacement.

WHY LEUCODEPLETION

Donor lymphocytes do not serve much purpose but can lead to major side effects.

Antibodies can develop against lymphocytes and platelets and leads to NHFTR.

Activated lymphocytes can release Cytokines like IL-2,TNF during storage, which can also cause NHFTR.

NHFTR is especially a problem for patients needing recurrent transfusions.

Lymphocytes lead to allo-sensitization and subsequent graft rejection in prospective candidates for bone-marrow transplants.

Lymphocytes bear intracellular pathogens and can transmit infections like HIV,HTLV,EBV,CMV etc.

Lymphocytes can lead to pulmonary toxicities like ARDS.

In surgical pts lymphocytes can lead to immune suppression and delay healing.

Hence all these components can lead to all the above-mentioned lymphocyte mediated toxicities.

Ideally all the transfusion should be leuco-depletedespecially in patients needing recurrent transfusions and in immuno-compromised hosts.

METHODS OF LEUCODEPLETION

1.WBC filters: • 3rd generation WBC filters are highly efficient. Efficacy is 99.5% They contain fiber mesh to which the WBC stick and

get filtered. when used during collection itself they will remove lymphocytes at source and hence prevent release of cytokines on storage.

They can also be used at the bedside while transfusing the blood.

ADVANTAGE: high efficacy Simplicity to use.

DISADVANTAGE: High cost Inability to prevent TAGVHD. Each filter costs Rs.600-700/- and is not

reusable. Ideally all transfusion should be

given using filters especially if patient needs recurrent transfusions or develops NHFTR.

2.WASHED CELLS

Washing with saline or blood processor not only removes WBC but also plasma.• Efficacy of WBC removal is 90% and that of plasma is

99%.• Hence it not only will reduce NHFTR, allosensitization

toxicities related to WBC but will also reduce allergic reactions to plasma proteins.

• Preparation is simple.DISADVANTAGE:• Not very effective in leucodepletion and cannot

prevent TAGVHD.• It needs cold centrifuge to prepare washed cells.

All red cell transfusions should be given using at least washed cells and preferably

with WBC filters in pts needing recurrent transfusions and those with NHFTR or allergic reactions.

Washed platelets from mother are given to a baby suffering from allo-immune

thrombocytopenia.

3.gamma-irradiation:• TAGVHD can be prevented only with gamma-

irradiation of blood.

DISADVANTAGE:

Need for sophisticated irradiator and chances of membrane leak of the cells irradiated and

increased K+ levels.

• Hence blood should be irradiated just before infusionOr else supernatant plasma should be removed before transfusion

Ideally all blood should be irradiated where there is risk of TAGVHD.

This includes: Transfusion in newborns especially pre term

<1200gms Intrauterine transfusion.

Pt with primary or secondary immunodeficiency.

Organ transplant recipients Transfusion given to a normal person from a first degree relative donor

4.FROZEN CELLS

RBC can be frozen at -70°C and be kept for 5-7yrs.

Once thawed should be used within 24 hrs.

Efficacy for leucodepletion is 90% and plasma depletion is 99%.

Hence it reduces toxicities related to both lymphocytes and plasma.

ADVANTAGE

Availability in emergency where one can use o-ve frozen cells in AB–ve plasma.• One can collect blood from CMV negative donors.• HLA matched donor or rare blood group donor and freeze it for future use.• Lastly autologous blood collected for surgery

can be frozen and used in future, if surgery gets postponed for some reasons.

DISADVANTAGE:• Needs sophisticated instruments to prepare and

store.• Extremely costly.• It cannot prevent TAGVHD.

PLATELETS TRANSFUSIONS

PLATELETS -DESCRIPTIONS:o Prepared from a random unit of whole blood

collected in CP2D anticoagulant solution.

o Suspended in a small amount of the original plasma. o A unit contains at least 55 x 109 platelets suspended in

50-55 mL of plasma.

o Platelets may also be obtained by apheresis

TYPES OF PLATELETS

RANDOM DONOR

SINGLE DONOR

PLASMA DEPLETED PLATELETS

WASHED PLATELETS

WBC FILTERED

UV OR GAMMA IRRADIATED

PLATELETS FROM SPECIFIC DONOR:

CMV NEGATIVE OR HLA-MATCHED DONOR.

PLATELETS

Contents

Platelets

WBC’s

Plasma

PRBC

PLATELETS TRANSFUSIONS

Platelets stored at 20 to 24°C on constant agitator.

It should be transported quickly and infused rapidly over 20-30 minutes to prevent loss of platelets due to aggregation.

Should use only ABO/Rh identical compatible donor.

In emergency one can use incompatible donors though the efficacy may be less than expected.

PLATELETS- FUNCTION:

Prevent bleeding of injured blood vessel walls by forming an aggregate at the site of injury.

Participate in blood coagulation, inflammation and wound healing.

The transfusion of platelets to a patient with thrombocytopenia or bleeding should produce a rise in the platelet count and control bleeding.

PLATELETS - INDICATIONS:

o Bleeding due to severely decreased production or abnormal function of platelets.

Prophylacticaly to patients with rapidly falling or low platelet counts, less than 10 x 109/L (10,000/uL), secondary to bone marrow failure, cancer or chemotherapy.

Postoperative bleeding with platelet count less than 50 x 109/L (50,000/uL).

RANDOM DONOR PLATELETS Also called PLATELET PACK Derived from SINGLE UNIT of whole blood. Contains 5-6×10¹º in 50-60ml of plasma per pack. One unit per 10 kg will raise platelet count

by 20,000 to 30,000/cmm. ADVANTAGE

Less costly and easily available.DISADVANTAGE Expose recipient to more no of donors. One cannot use specific donor like CMV negative or

HLA matched

PLATELETS APHAERESIS

SDP: collected from a single donor via aphaeresis using cell separator and are suspended in plasma.

Also called platelet concentrate.

Volume: 150-300mL (actual volume is specified on the label)

Platelet Count: >150-500 x 109/unit.(Equivalent to 3-10 single donations.)

ADVANTAGE:o More concentrated hence more effective. Exposing recipient to only a single donor. One can use same donor again after 2-3

weeks. One can select specific donor.

DISADVANTAGE: Extremely costly. Needs sophisticated equipments. Donor has to wait for longer periods in blood

bank.

CRITERIA TO TRANSFUSE:

Usually given to those with thrombocytopenia due to decreased production than to those with increased destruction.

Platelet transfusion are given when they have significant mucosal bleeds.

Only skin bleeds do not warrant platelet transfusion, but such patients should be closely monitored for any further mucosal bleeds.

IJPP

PROPHYLACTIC PLATELET TRANSFUSION

Always controversial Child with thrombocytopenia usually do not bleed

unless the platelet count fall <50,000.Decision when to transfuse is hence based on basic disease, type of thrombocytopenia, platelet count, and presence of associated coagulation abnormalities.Well child –prophylactic transfusion with count<5,000-10,000/mm3.Sick child-transfusion given with count <10-20,000.Before surgery-<30,000 but eye surgery<50,000.Massive hemorrhage<30,000.as most of the platelets are non-functional platelets of stored blood.

GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION

CHILDREN AND ADOLESCENTS PLTs<50,000 and bleeding.

PLTs<50,000 and invasive procedure.

PLTs<20,000 and marrow failure and hemorrhagic risk factors.

PLTs<10,000 and marrow failure without hemorrhagic risk factors.

PLTs at any count but with PLT dysfunction plus bleeding or an invasive procedure.

GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION

INFANTS WITHIN FIRST 4 MO OF LIFE PLTs<100,000 and bleeding.

PLTs<50,000 and an invasive procedure.

PLTs<20,000 and clinically stable.

PLTs <100,000 and clinically unstable.

PLT at any count, but with PLT dysfunction plus bleeding or an invasive procedure.

Patient’s ABO

Group

Platelet Product Group

First Choice

Second Choice

O O  

A A B

B B A

AB AB B or A

INDICATIONS :PLATELETS Platelet transfusions are given for thrombocytopenia

or for platelets dysfunctional disorders.1.DECREASED PLATELETS PRODUCTION: Bone marrow failure - Aplastic anemia -Fanconi anemia -TAR syndrome -other constitutional hypoplastic anemia. Bone marrow infiltration -leukemias and metastatic cancers. Bone marrow suppression-fulminant infections Indian journal of practical pediatrics

2.INCREASED CONSUMPTION OF PLATELETS:DICNECHUSTTPGood platelet recovery at 1 hr after transfusion,but not at 24 hrs suggesting consumption.

3.INCREASED PLATELET DESTRUCTION: Immune or non-immune . Post-transfusion purpura, auto-immune disease, ITP,

allo-immune disease of newborn. Non-immune: drugs and infections Platelet transfusion is NOT EFFECTIVE in this group as they will be immediately destroyed

after transfusion

However ,in life-threatening bleeding like intracrainial hemorrhage one may give platelet packs just to tide over crisis till splenectomy is done or IVIG is administered.

Allo-immune thrombocytopenia of newborn: Washed mother´s platelets are given to the

baby. 4.HYPERSPLENISM:Platelet transfusion may

not be effective as they will be immediately removed from circulation into enlarged spleen.

5.DILUTIONAL THROMBOCYTOPENIA:When massive amount of whole blood is used.Requires additional platelet transfusion

6.Platelet –dysfunction: various congenital and acquired platelet functional disorders

may present with significant bleeding .

o If local measures fail to control bleeding transfusion will be required.

o One should use platelets sparingly as allo-sensitization may prevent good recovery in future after a number of transfusions are given.

o One can use HLA matched platelets in such cases.

Platelet transfusion efficacy: One unit of RDP per 10 kg body wt increase

platelet count by 20,000 to 30,000/cmm.

SDP is 5-7 times more efficacious than RDP.

Efficacy of platelet transfusion depend upon:Source, type, storage, collection and administration will affect the efficacy.

Pre-transfusion count, fever, sepsis, size of liver and spleen, presence of antibodies or consumption coagulopathy and drugs taken by recipient.

CLINICALLY one can judge efficacy by looking at the cessation of bleeding.

PLATELETS – CONTRAINDICATIONS:

Bleeding is unrelated to decreased numbers or abnormal platelet function.

Consumption of platelets, in Thrombotic Thrombocytopenia Purpura (TTP) Idiopathic Thrombocytopenia Purpura (ITP), Unless the patient has a life threatening hemorrhage.

o Untreated DIC.o Thrombocytopenia associated with septicemia,untill

treatment has commenced or in cases hypersplenism.

PLATELET INCUBATORStored with constant

agitation

Recycle Life through a Plateletpheresis Donation

This is John A. Zendt, a Moody Gardens Employee donating platelets and plasma.Do you want to become an Apheresis Donor?

Recycle Life through a Platelet Aphaeresis Donation

GRANULOCYTES

Patients with severe uncontrollable infection. Congenital or acquired neutropenia. Usually reserved for neutropenic pts with

fulminent sepsis not controlled by antibiotics and antifungal ANC<300 in newborn,

<100 in infants and <500 in immunocompromised

host. It should always be used along with antibiotics

and antifungal.

GRANULOCYTES

Granulocytes in newborns -partial exchange with fresh whole blood to replace granulocytes.

DOSE:10-15ml/kg body wt. Can be repeated 12-24 hrly for 4-6 days. It is to be stored at room temperature and

to be used within 24 hrs. It has all side-effects related to plasma and

lymphocytes. Should be used ABO/Rh compatible donor.

FRESH FROZEN PLASMA - FFP DESCRIPTION: Platelet poor plasma obtained at the end of

centrifugation while making components is frozen within 4-6 hrs

at -30ºC to make FFP. It can be obtained from a whole blood donation

(approx. 250 mL) or by apheresis (approx. 500 mL).

Shelf life is one year.

FFP contains all plasma proteins including albumin, gamma-globulins and a normal concentration of fibrinogen and the labile coagulation factors VIII and V.

FRESH FROZEN PLASMA -DESCRIPTION:

One unit of FFP has 150cc-200cc of plasma and 1ml of plasma contains approx 1 unit of each clotting factor.

One can use 10-15 cc/kg body weight of FFP every 12 hrly.

Hence one cannot raise factor levels beyond a certain limit without leading to volume overload.

FRESH FROZEN PLASMA –INDICATIONS: The majority of clinical situations for which FFP

is currently used do not require FFP.Pt presenting with bleeding for the first

time where the diagnosis is uncertain as to which factor is deficient.

Massive transfusion with a demonstrated deficiency of Factor VIII and V, otherwise frozen plasma is adequate.

Exchange transfusion in neonates.

FRESH FROZEN PLASMA – INDICATIONS:

Mainly used to replace clotting factors. Where multiple factors need to be replaced

liver disease, DIC,TTPWarfarin anticoagulant overdose.Pts receiving large volume of whole blood.Antithrombin III deficiency

In reconstitution of whole blood along with PRBC or to adjust hematocrit of PRBC for exchange

transfusion in newborn.

Lastly FFP is useful to prevent and treat coagulopathy due to L-asperagenase in cancer pts.

Hemophilia ,it is better to use factor concentrate.

FRESH FROZEN PLASMA As FFP contains plasma, it can lead to

allergic reactions, anaphylaxis in IgA deficient patient and can transmit all the plasma borne infections.

Hence albumin should be used as a volume expander as it is much safer.

Similarly albumin and not FFP should be used to replace proteins or albumin.

If pt need both volume expansion as well as clotting factors like in DIC, sepsis, NEC etc. one can use FFP.

In small babies, it can lead to hemolysis if it contains high levels of antibodies against recipient’s blood group antigen

FRESH FROZEN PLASMA - CONTRAINDICATIONS:

Should not be used when coagulopathy can be corrected more

effectively with specific therapy, such as vitamin K, cryoprecipitate, or Factor VIII concentrates.

Same infectious disease risk as whole blood.

Should not be used when the blood volume can be replaced with other volume expanders such as

0.9% sodium chloride, lactated ringer’s, albumin.

CRYOPRECIPITATE (CRYO) DESCRIPTION: Cryoprecipitate is prepared by thawing fresh

frozen plasma at a temperature between 1°C and 6°C.

After centrifugation, the supernatant plasma is

removed and the insoluble cryoprecipitate is refrozen.

On average, each unit of cryoprecipitate contains 80 IU or more Factor VIII (FVIII:C) and at least 150 mg of fibrinogen in 5-15 mL of plasma.

CRYOPRECIPITATE (CRYO) INDICATIONS:

Source of fibrinogen or Factor XIII.

It may be used as a source of Factor VIII only when inactivated fractionation products or recombinant Factor VIII are not available.

Fibrinogen and fibronectin are present.

CRYOPRECIPITATE (CRYO) CONTRAINDICATIONS:Should not be used unless results of laboratory

studies indicate a specific haemostatic defect.

Specific factor concentrates are preferred.

CRYOPRECIPITATE (CRYO)

Cryoprecipitate Pooling Cryoprecipitate

Patent IV access and is ready to receive the transfusion.

Check medical orders: product type, special requirements and administration

requirements.

Checks prior to administration of the blood product:

Patient identification- Name, DOB and UR on the blood transfusion record, blood product and tag and on the patient's wrist band.

PRE-TRANSFUSION CHECKS

PRE-TRANSFUSION CHECKS• If parent or guardian or child of

appropriate developmental age,include them in the patient identification

checking product.  Blood product for any signs of leakage,

clots or abnormal colour.Complete documentation:

sign, date, start and finish time.• Blood Transfusion Record and file in the

patient's medical record.

PRINCIPLES OF BLOOD COMPONENT THERAPY

• Beware of the indications, risks and benefits.

The cause of the deficiency should be identified.

Alternatives to transfusion considered.

Only the deficient component should be replaced.

The product should be as safe as possible.

Informed consent and documentation should be part of the process

SAFE ADMINISTRATION OF BLOOD

Involve following:1.accurate identification of patient.2.correct labeling of blood sample for pre-transfusion testing.3.After receipt from blood bank proper storage in the clinical area upto time transfusion is given.4.A final patient identity check to ensure the administration of the right blood to the right pt.

RISK TO THE PATIENT FROM BLOOD TRANSFUSION

With the highest levels of standards, working sophistication, best of equipments and

trained personnel there are inherent risks in blood transfusion.

Some are preventable and on some there is no control.

With the present day methods there are almost negligible technical errors.

Most of the errors are clerical and result from disregard to the standard procedures.

COMMON RISKS TO PATIENT

Blood meant for one pt transfused to another pt.

Blood pack which has been infected.

Heating or freezing of the blood.

Transfusion transmitted diseases.

Adverse reaction to the blood transfusion.

DOCUMENTATION AND MONITORING

Document vital signs 1 hr prior to administration.

Immediately after commencement.

Minimum of 15 minutes after starting.

Hourly until transfusion is completed.

20-60 minutes following completion of transfusion.

CARE OF TRANSFUSED PATIENTS

o Must be undertaken for each unit transfused.

o Monitoring- adverse effects of transfusion closely during the first 15 minutes as a minimum take.

o Record vital signs: Temperature, Pulse, Respiration and Blood Pressure Before commencement 5 minutes after commencement On completion 

More frequent observations particularly in unstable/unconscious patients.

TRANSFUSION REACTIONSREACTION ACUTE

(WITHIN 24 HRS)DELAYED(onset within days or months)

IMMUNE MEDIATED Hemolytic Hemolytic

Febrile non-hemolytic alloimmunisation

Allergic Post-tr purpura

Anaphylactic TAGVHD

TR-acute lung injury Immunomodulation

NON-IMMUNE MEDIATED Bacterial contamination Infections-HBV,HCV

Circulatory overload HIV-1&2

Hyperkalemia Syphilis

Thrombophlebitis Malaria

Iron-overload

TRANSFUSION REACTIONS

Febrile Reactions

• Incidence ： 2%

• Chills, Fever 39-40.C

• Headache, Sweatiness

• Nausea, Vomiting, Flushing

• 15min-1hr

TRANSFUSION REACTIONS•Febrile Reactions ：

•Treatment ：

Immuno-reaction ： Endo-toxins ： Contamination or Hemolysis ：

Analyze possible reasons ： Stop Transfusion ： General Support ：

TRANSFUSION REACTIONS•Anaphylactic reactions ：

• Urticaria

• Abdominal cramps

• Dyspnoea

• Vomiting

• Diarrhea

ANAPHYLACTIC REACTIONS ：

•Reason ： Immuno-reaction ：　 IgE

Hereditary Immunoglobulin ：　 　 IgA

•Treatment ： Administer antihistamines

Administer epinephrine, diphenhydramine, and

corticosteroids ： Support airway and circulation as necessary ：

TRANSFUSION REACTIONS

• Burning at the intravenous (IV) line site

• Fever, Chills, Dyspnoea

• Shock

• Cardiovascular Collapse

• Hemoglobinuria, Hemoglobinemia

• Renal Failure

• DIC

Hemolytic transfusion reactions

HEMOLYTIC TRANSFUSION REACTIONS

•Reasons ： ABO incompatibility

Rh Incompatibility

Non-immune Hemolysis

Immune Hemolysis

•Treatment ：

Stop Transfusion as soon as reaction is suspected

Check the name, type and cross-match

Urine Exam

Renal Protection

(Aggressive Fluid Resuscitation,

Furosemide)

DIC Monitor

COMPONENT TRANSFUSION ：• Saving blood source

• Less likely carrier of transmitted diseases

• Shortage of quality blood

• Greater shelf life than whole blood

• Helping to make blood safer by filtration

• Infusing regardless of ABO type in some blood

products

give only essential/desired blood component

HAEMOVIGILANCE

Set of surveillance procedures from the collection of blood to the follow-up of recipients for any untoward effect in order to prevent them in future.

Notification of transfusion-incidents by the French health authorities became a legal obligation.

The concept was introduced in 1993 when the Blood Transfusion Safety Act in France was adopted.

HAEMOVIGILANCE

The parties (or institutions) include all blood establishments, treating

physicians, transfusion committees, and consumers (recipients).

The process of 'haemovigilance' is already operational.

•Blood Safety Programme in India was initiated in 1989-90.

• Which subsequently became an integral part of the National AIDS Control Program (NACP)

•The WHO recommends that all donated blood should be tested for HIV/AIDS with either ELISA or

RAPID /SIMPLE test. •Besides, it is mandatory to test blood for hepatitis,

syphilis, and malaria.

Blood Safety

INDIA MARCHES TOWARDS SAFER BLOOD TRANSFUSION!

Now in INDIA the blood donation by professional donors is banned.

• Voluntary blood donation is encouraged.

• Screening of blood is compared as on 1991-92 (Mar-Apr) and 1996-97.

• Donors are screened for syphilis (VDRL), HBV (HBsAg), HIV (ELISA & W Blot) and malaria (MP).

.

• In 1996-97: 8 VDRL+, 19 HBsAg+

6 HIV+. No malaria+.

INDIA MARCHES TOWARDS SAFER BLOOD TRANSFUSION!

• Recipients tested for HIV after 6 months of transfusion.

• 1991-92 : 64- VDRL+ 51- HBsAg+ 2 -HIV+. No malaria+.

India marches towards safer blood transfusion!

There is reduction in VDRL+ and HBsAg+.

But the increase in HIV positivity reflects the progression of seroconversion in the

general population.

CONCLUSION: Comparatively in 1996-97 the donor samples contain less infectivity

and less contamination.

THANKS