blood & blood products

Blood & Blood Products

S.LaxinyMedical StudentFHCSEUSL

Blood-Whole Blood

Fresh Whole Blood

Blood Products

Cellular Components-Red Cell Concentrates

Platelet Concentrates

Granulocyte Concentrate

Plasma Components-Fresh Frozen plasma

Cryoprecipitate

Cryopoor plasma

Stored plasma

Plasma Derivatives-Albumin

Immunoglobulin

Coagulation Factors

Transfusion practice in Paediatrics

For transfusion purpose,there are two groups of children

1.Neonates and infants <4 months

2.Infants >4 months and children

Neonates and infants <4 months-

No demonstrable amount of anti-A & anti-B

In infants >4 months & children-

Blood grouping

Antibody screening

Cross matching

Blood volume

Premature baby 100ml/kg

Full term baby 85ml/kg

Infant 72ml/kg

Children 76ml/kg

Adults 80ml/kg

Hemoglobin concentration in children

Age Hb concentration g/dl

Cord blood +16.5

Day 1 +18.0

1 month +14.0

3 months +11.0

6months-6 years +12.0

7-13 years +13.0

Amount to be transfused must br carefully calculated,

Whole Blood (WB)

Whole Blood (WB)

• Whole blood=Donor blood + Anticoagulant• 1 Unit-450ml• Anticoagulant (CPDA-1)-63ml• No functional platelets• No labile coagulation factors• WB is used for component preparation.• Hct-45%• Stored at 2-60c • Shelf life-35 days

Whole Blood

Mandatory screening tests

• HBsAg• Anti-HCV• Anti-HIV 1 & 2• VDRL/ TPPA• Malarial Parasite

Fresh Whole Blood

Packed Red Cells

Light spin, 22oC(within 8 hrs)

Platelet Rich Plasma

Platelet Concentrate Fresh Plasma

Store at 22oC Freeze(FFP)

Heavy spin,22oC

Preparation of blood components from whole Blood

Whole Blood

Indications

• Acute blood loss with hypovolaemia• Exchange transfusion-severe anaemia at birth

severe hyperbilirubinaemia• Massive transfusion• Cardiovascular bypass surgery

Whole BloodRisk of volume overload : Chronic anaemia Cardiac failure

Dose of blood transfusion-20ml/kg

Increase Hb by 1 g/dl

Rate of Blood Transfusion-3ml/kg/hr

Transfusion considerations-ABO compatible

Cross match compatible

Start transfusion slowly

Whole Blood

Potential Adverse Effectso Reactions-Haemolytic

Febrile

Allergic

Anaphylactico Infectious diseaseso Sepsiso Circulatory overloado TA-GVHDo TRALI

Fresh Blood

Blood < 5 days

Source of coagulation factors, platelets

& WBC

Blood <5days for Exchange transfusion in

newborns-to prevent hyperkalemia

& to supply red cells with adequate

content of 2,3-DPG.

Blood Products

Red Cell Concentrates

Platelet Concentrates

Granulocyte Concentrate

Fresh Frozen plasma

Cryoprecipitate

Cryopoor plasma

Stored plasma

Albumin

Immunoglobulin

Coagulation Factors

Plasma Derivatives

Plasma Components

Cellular Components

Blood

Red Cell Concentrates Also called Packed Red Cells Platelets and plasma are removed I Unit- 200- 250ml Hct-65-75% Shelf life-35 days Stored at 2-40c Preferable to transfuse immediately


Indications

Anaemia

Thalassemia

Sickle cell disease

Guidelines for Paediatric red cell transfusions

Anaemia

Infants within first 4 months of life

• Hb< 13.0 g/dL and severe pulmonary disease • Hb < 10.0 g/dL and moderate pulmonary disease • Hb < 13.0 g/dL and severe cardiac disease • Hb < 10.0 g/dL and major surgery • Hb < 8.0 g/dL and symptomatic anemia • Acute blood loss >10% of total blood volume.

Guidelines for Paediatric red cell transfusions

Infants >4 months & children

• Acute loss > 25% circulating blood volume • Hb < 8.0 g/dL in perioperative period • Hb < 13.0 g/dL and severe cardiopulmonary

disease • Hb < 8.0 g/dL and marrow failure • Hb < 8.0 g/dL and symptomatic chronic anemia


Autoimmune hemolytic anaemia

• RCC to prevent coronary insufficiency,

congestive heart failure, cardiac

decompensation or neurological impairment.

• Transfusion may stimulate autoantibody

production complicating subsequent

transfusion.


Thalassemia

• Periodic regular blood transfusions

• Every 3 or 4 weeks

• Rate 2-3 hours/unit

• Pre transfusion Hb level -9-10g/dl

• Post transfusion Hb should not rise >14g/dl


Thalassemia

• Annual blood consumption=total blood transfused over 12 months/patien’s weight in middle of the year.

• If blood consumption is >200ml/kg BW

spleenectomy should be

considered

Sickle cell disease

Indications for simple top up transfusion

• Severe anaemia

• Splenic or hepatic sequestration

• Aplastic crisis

Indications in surgery

• Organ transplantation

• Eye,major abdominal surgery

Don’t raise >10g/dl=raise viscosity



cardiac failure-3-5ml/kg


Rate of Blood Transfusion -3ml/kg/hr

Adverse effects :Same as Whole blood

Leucoreduced Red Blood Cells

Most plasma & 70-80% WBC(buffy coat)

removed &100ml of AS added.

Indication

Symptomatic anaemia

Suitable for patients requiring repeated

transfusions.

Prevent febrile non haemolytic reactions.

Leucoreduced Red Blood Cells

• WBC : <5 108 /L

• Hct : 50–60 %

• Volume : 350 ml

• Shelf life : 42 days

• Stored at 2- 60c


Rate of Blood Transfusion -3ml/kg/hr


Transfusion considerations-ABO identical

Crossmatch compatible

Adverse effects :Same as Whole blood except

febrile reactions

.

•

Leucodepleted Red Blood Cells

Same as leucoreduced RBC But WBC <5106 / L Hct : 50–60 % Volume : 350 ml Shelf life : 42 days Stored at 2- 60c

Indications: Symptomatic anaemia Prevent febrile non haemolytic reactions. Suitable for patients requiring repeated transfusions.

Washed Red Blood Cells

• RBC washed with 1-2 L Normal Saline• RBC : 20% reduced• Plasma 90% reduced• WBC : 90% reduced

• WBC count: <5 108 /L

• Prevent febrile non hemolytic reactions.• Washing eliminates antibodies & other

plasma constituents• Indications: Symptomatic anemia• Transfuse within 6 hours

Washed Red Blood Cells

Indications

Multitransfused patients with

recurrent febrile reactions Urticarial reactions Anaphylactic reactions IgA deficiency with IgA antibodies Paroxysmal nocturnul hemoglobinuria Patients with T activated cells by infections

who require transfusion

ABO group selection for RBC Transfusion

Recipient ABOGroup

Component ABO Group

1st Choice 2nd Choice 3rd Choice 4thChoice

A A O None None

B B O None None

AB AB A B O

O O None None None

Oh (Bombay Group)

Oh None None None

Platelets Concentrate

Types of Platelets

o Recovered platelets(Random donor platelets)o Apheresis platelets(single donor platelets)


Random donor platelets

o Made from a unit of whole blood.

Prepared by 2 methodso Platelet rich plasmao Buffy coat removal

o I unit :50109 plateletso Volume: 50 ml


Single donor platelets

o Made from single donor

o Apheresed using cell separator machine

o 1 unit SDP: 300109 = 6 units RDP

o Volume of 1 unit SDP: 200-350 ml


o Stored at 200c-240co Shelf life: 5days

o Once issued should be transfused as soon

as possible

Useso Prophylactico Therapeutic


Guidelines for Pediatric Platelet Transfusions

INFANTS WITHIN FIRST 4 MONTHS OF LIFE

PLTs < 100 × 109/L and bleeding

PLTs < 50 × 109/L and invasive procedure

PLTs < 20 × 109/L and clinical stable

PLTs < 100 × 109/L and clinically unstable

PLTs at any count, but with PLT dysfunction

plus bleeding or invasive procedure


CHILDREN AND ADOLESCENTS

PLTs < 50 × 109/L and bleeding

PLTs < 50 × 109/L and invasive procedure

PLTs < 20 × 109/L and marrow failure with hemorrhagic risk factors

PLTs < 10 × 109/L and marrow failure without hemorrhagic risk factors

PLTs at any count, but with PLT

dysfunction plus bleeding or invasive procedure


Contraindications

o TTP(Thrombotic Thrombocytopenic Purpura)o HIT(Heparin Induced Thrombocytopenia)

o Should be ABO compatible

ABO group selection for Platelet Transfusion

Recipient ABO

Component ABO


A A AB B O

B B AB A O

AB AB A B O

O O A B AB

Granulocytes

1. Granulocyte concentrate

2. Buffy coat

Granulocyte concentrate

Prepared by apheresis 1 unit Contain 1 1010 Granulocytes Volume: 200-300 ml 1 or more units daily

Granulocytes

Buffy Coat

Layer between red cells & plasma I unit: 1-2 109

Volume: 50 ml Stored at 220c-240c Shelf life -1 day Should be ABO & Rh specific Should be irradiated to prevent GVHD Dose-10 units/day Should be administered within 12 hours.

Granulocytes

Indications• Severe neutropenia (<0.5 109/L) with

severe infections

Contraindications• Bone marrow failure• sepsis • PUO

Irradiated blood products

• Inactivate T-Lymphocytes• Prevent GVHD• Shelf life-28 days

Indications• Bone marrow/ stem cell transplant• Intrauterine transfusions• Congenital immunodeficiency syndrome• Premature newborn• Neonatal exchange transfusion-give within

24 hours.

Blood warming

• Warming is not necessary for routine transfusions.

• Warming of blood increase red cell metabolism & bacterial growth.

• Electric warmer or water bath is used to warm blood

Indication• Exchange transfusion in neonates• Presence of cold agglutinins• Rapid infusion through CVP lines

Blood Donation EmblemBlood Donation Emblem

Plasma components

Fresh Frozen plasma

Cryoprecipitate

Cryopoor plasma

Stored plasma

Fresh frozen plasma

Fresh frozen plasma

Contains• All coagulation factors

• Plasma proteins

Indications• Single clotting factor deficiency• Multiple clotting factors deficiencies-DIC

• Massive transfusions,

• Warfarine overdose

• Haemorrhagic disease of neonates

• TTP

Not recommened• Plasma volume expansion

FFP

DOSAGE• 12-15ml/kg (1unit – 200-250ml)• Must be ABO compatible• Storage temperature: <-300c• Thawed in blood bank at 370c

Thaw at 4oC & heavy spin

Fresh Frozen Plasma

Cryoprecipitate

-Refrozen within 1 hr

-Store at < - 18oC

Cryoremoved Plasma

Freeze -80oC immediately

Stored at < -18oC

Cryoprecipitate (CRYO)

I unit Contains• FVIII, FXIII, vWF,

• Fibrinogen

• I unit =15 ml• Stored at -300c

Cryoprecipitate (CRYO)

Indications• Hemophilia A• Von Willebrand’s disease• FX111 or fibrinogen deficiency

Dose• Depend on desired Factor level

• ABO compatibility

• Rate 10-15ml/min

• Transfuse immediately

Cryopoor Plasma / Cryosupernatant

Contains• Stable clotting factors• No factor 8 & fibrinogen

Indication• Replacment in plasma exchange for TTP

Stored plasma

Anticoagulant factors containing preservative solution

Contain stable clotting factorsNo labile coagulation factorsVolume: 200-250 mlShelf life-1 year

IndicationPlasma protien deficiency

ABO group selection for Plasma/FFP Transfusion

Recipient ABO

Component ABO


A A AB None None

B B AB None None

AB AB None None None

O O AB A B

World Blood Donor Day-June 14th

Plasma derivatives

• Factor VIII• Factor IX• Factor VIII- vWF concentrates

1. Factor VIII

Indication-

Hemophilia A

Loading dose,maintenance dose

Loading dose = desired factor VIII level –

patient’s baseline level Body weight(kg)/2

Plasma derivatives

2.Factor IX

Indication-

Hemophilia B

Loading dose + maintenance dose

Loading dose=desired factor IX level –

patient’s baseline level Body weight(kg)

Plasma derivatives

3.Factor VIII- vWF concentrates

• Indications-

• Type IIB & severe type III Von Willebrand’s disease

• Mild disease-FFP

• Moderate disease-cryoprecipitate

Plasma derivatives

Albumin

2 preparations• Human albumin solution4.5%(plasma

protein fraction)• Human albumin solution20%(salt poor

albumin)

Indications• Nephrotic syndrome• Liver disease with fluid

overload

Plasma derivatives

Immunoglobulin

Normal immunoglobulin• Prepared from normal plasma

Indications• Hypogammaglobulinaemia• Infections• Immune thrombocytopenic purpura

Specific immunoglobulins• Obtained from donors with high titres of

antibodies• Eg- anti-D, anti-hepatitis B& anti-varicella

zoster

Adverse reactions of Blood Transfusion

Classification –acute

delayed

Causes Incorrect blood component transfusion Error in collection Error in storage Error in administration of blood, Mistakes in compatibility testing, Laboratory errors

Acute Transfusion Reactions

Acute adverse reactions-<24hrs

2 types

1.Immunologic

2.Non immuologic

Immunologic Adverse reactionsHaemolytic transfusion reaction

Febrile non-hemolytic transfusion reaction

Allergic

Anaphylaxis

Transfusion related acute lungs injury (TRALI)

Acute reactions

Non immuologic acute reactions

Marked fever with shock Atypical reaction with hypotension Congestive heart failure Air embolism Hypocalcaemia Hypothermia Hypokalemia and hyperkalemia Thrombophlebitis

Delayed adverse reaction

• >24hrs

2 types

1)Immunologic reactions

2)Non immuologic reactions

Immunologic reactions• Alloimmunization to RBC,WBC,platelets,

Plasma protein&HLA• Haemolytic reactions• TA-GVHD• Post transfusion purpura

Delayed adverse reaction

Non immuologic reactions

• Iron overload• Transfusion transmitted diseases

Acute Haemolytic transfusion reaction

Etiology-ABO incompatibility

Clinical features

Symptoms

Chills

Chest pain

Back pain

Nausea, vomiting

Flushing, sweating

Pain at infusion site

Abdominal discomfort

Restlessness

Acute Haemolytic transfusion reactionSigns

Fever with rigors

Tachycardia

Dyspnoea

Tachypnoea

Pallor

Hypotension

Hemoglobinuria

Anuria / Oliguria

Cyanosis

Shock & DIC


Lab evidence

DAT positive Indirect bilirubin increased Hemoglobinemia Hemoglobinuria


Management Stop transfusion immediately Maintain IV access with crystalloid Maintain BP,pulse Ventilation & oxygenation IV diuretics-mannitol IV

frusemide IV bolus Send blood samples to blood bank-5ml of

plain blood & 2ml of EDTA blood FBC and blood picture Urine sample for hemoglobinuria


If intravascular hemolysis is confirmed

• Monitor renal status• Monitor coagulation status• If hb is markedly reduced ,compatible red

cell transfusion may be required to combat hypoxemia.

• Treat DIC if it occurs

Delayed Haemolytic transfusion reaction

• 3-7 days after the transfusion• Most common in multiparous women &

mulitple transfusions.

Etiology-immunologic response to donor red

cell antigen


Clinical features• Fever • Jaundice• Dark coloured urine

Lab evidence• Absence of anticipated Hb or HCT• Indirect hyperbilirubinemia• DAT positive


Diagnosis

Presence of alloantibodies in post transfusion

sample

Treatment• Rarely necessary• Observe urine output• Transfuse of blood that lacks the

responsible antigen.• Issue medical card to these patients.

Febrile Non Haemolytic Transfusion Reaction

Etiology- Antileucocyte antibodies against donor leucocytes& cytokines from donor leucocytes

Clinical features• 1-2 hours later• Fever ,chills&rigors• Flushing• Tachycardia

Febrile Non Haemolytic Transfusion Reaction

Management

• Stop transfusion• Restart slowly• Treat with oral paracetamol• saline washed or leucoreduced cells

Transfusion tranmissible infections

Viral infections

• Hepatitis A, B, C• HTLV-1 & HTLV-2• HIV-1 & HIV-2• CMV• EBV• West Nile Virus

Prion-eg.new variant CJD


Protozoal infections

• Trypanosoma cruzi (Chaga’s disease) • Malaria• Toxoplasmosis• Leishmaniasis

• Use HBV vaccine,prophylactic anti malarial in regularly transfused patients


Bacterial contamination• Rare condition• Cause death• Most frequent – Yersinia enterocolitica

Causes Inappropriate storage conditios Improper blood warming Keeping blood in domestic refrigerators Delay in initiating blood transfusion Transfusion over > than 4 hours stored at room temperature-platelets Addition of any medication to blood bag.


Bacterial contamination

Clnical featureso Fever 40 0 C o Hypotensiono Collapse shocko Abdominal cramps,nausea,vomitingo DICo Hemoglobinuriao Intravascular hemolysiso Renal failure



Clinical features• Fever 40 0 C with rigor immediately

after transfusion• Hypotension,collapse ,Shock• Abdominal cramps,nausea,vomiting• DIC,haemoglobinuria,renal failure



Management

• Stop transfusion• Inspect blood bag for signs of bacterial

overgrowth.• Send sample for smear +culture• Treat the infection

Transfusion associated graft versus host disease

Etiology- engrafment of transfused functional

lymphocytes

Mortality>90-99%

10-12 day after transfusion

Clinical features• Jaundice & elevated

liver enzyme• Erythroderma• Diarrhoea• Pancytopenia

Skin manifestation of GVHD Generalized swelling, erythroderma and bullous formation

Transfuion associated graft versus host disease

Investigations

• Skin biopsy• HLA typing

Patients at risk

• All newborn & premature babies• Leukemia• All immunocompromised patients

Transfusion-Related Acute Lung Injury (TRALI)

Etiologyo Antibodies to leucocytes or complemento Within 4 hours

Clinical featureso Marked respiratory distresso Hypoxiao Hypotensiono Fevero Bilateral pulmonary infiltrateso Normal CVP

Transfusion-Related Acute Lung Injury (TRALI)

a b

(a)Bilateral patchy alveolar infiltrate in TRAL (b) Complete resolution

TRALI

Treatment

• High dose steroids -methyl prednisolone 1g IV bolus

• Ventilator support/ Oxygenation

Prevention

• Avoid use of plasma from multiparous females

• Use washed RBC• Use leucocyte filters

Post transfusion purpura

Etiology• Antiplatelet antibodies• 5-10 days after infusion

Clinical features• Acute severe thrombocytopenia in a

multiparous female or multiply transfused person

Post transfusion purpura

• Self limited recovery in 21 days

Treatment• IV immunoglobulin 2g/kg over 2-5 days• If not available-steroids or plasma

exchange

Prevention• Use leucodepleted components

Allergic urticarial reaction

Etiology• Antibodies to plasma protein

Clinical features• Itching• Urticaria• Rash• Flushing• Wheezing

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Allergic urticarial reaction

Treatment

• Transfusion can be continued• IV chlorpheniramine 10mg

Prevention

• If there is previous allergic reaction-give prophylaxis

• Use saline washed red cells

Anaphylactic reactions

Etiology- antibodies to IgA in transfused

blood• Occurs after infusion of few mls of blood

in IgA deficient patient

Clinical features• Tachycardia• Abdominal cramps• Diarrhoea• Loss of consciousness• Hypothermia,hypotension,shock• Absence of fever differentiates it from

other reactions.

Anaphylactic reactions

Treatment

• Stop transfusion• Start IV crystalloids• Give oxygen• Give chlorpheniramine 10mg slowly IV• Hydrocortisone 100-200 mg IV• Salbutamol nebulizer• If anaphylactic shock-give adrenaline

1:1000 solution 0.5ml IM• Send sample for IgA level• Use saline washed red cells

Iron overload

• Due to life long monthly transfusions

• In β thalassemia major

It results

• Cardiac failure

• Cardiomyopathy

• Liver cirrhosis

• Diabetes

• Delayed growth & sexual maturation

• Hyperpigmentation of skin

Guidelines for Clinical transfusion practices

• Record the reason for transfusion• Get the consent form signed by the patient.• Select the blood product & quantity to be transfused.• Fill the blood request form• Send 5ml recipient’s blood sample with the form.• Blood bank laboratory performs antibody screen &

compatibility test.• Check patient’s details with cross

match report from blood bank.• start administration of blood

within ½ hour of issue from blood bank.


• Record date & time of beginning &

termination of blood transfusion.• Use 23G needle to transfusion.• Check for air bubbles in transfusion line.• Hands should be washed.• Chamber half fill.• Monitor patient’s pulse,BP& temperature

prior to initiation & during blood transfusion.


• Observe the patient throughout transfusion.

• The first 30 minutes are crucial.• Monitor patients condition at the end of

blood transfusion.• Return transfusion record

form to the blood bank.• Observe the patient for 1 hour. • Monitor the post transfusion effects.• Dispose the blood bag with other

biohazard waste in the ward.

Don’ts for Blood Transfusion• Don’t use blood without mandatory screening

test.• Don’t delay initiation of blood transfusion.• Don’t warm blood without proper monitoring.• Don’t transfuse 1 unit over more than 4 hours.• Don’t use 1 transfusion set for >4 hours or >2

units of blood.• Don’t leave patients unmonitored.• Don’t add any medication to blood bags.• Don’t forget to return unused blood to the blood

bank for safe disposal.• Don’t store platelets in a refrigerator.

Thank You

blood & blood products

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