This diagram shows normal pcv of adult.in this the rbc which have highest specific gravity (1.08) tend to settle at bottom of test tube while the plasma(1.02) stays at the top in between there is buffy coat which contain wbc and platelet.
BLOODCOMPONENT THERAPY-II DR.SAURAV SINGH
TERMS APHERESIS: It is a Greek word that means to separate or to remove. In apheresis,blood is withdrawn from a donor or patient in anticoagulant solution and separated into components. One or more component is retained and remaining constituent are returned to the patient. PLASMAPHERESIS: The process of removing the plasma from red cells is termed plasmapheresis. Similarly terms are given to removal of other components like Platelet(PLATELETPHERESIS), Red
PLATELETSo There are two methods from which platelets can be obtained: ◦ Differential centrifugation of unit of whole blood (platelet concentration). ◦ Plateletpheresis Platelet concentration: Platelet concentrate is prepared from centrifugation of whole blood within 6hrs of donation and is centrifuged at low spin to produce platelet rich plasma(PRP)
• PRP is transferred to satellite bag and spun at high speed to get platelet (at bottom) platelet poor plasma (at top). Platelet poor plasma is returned to the primary bag leaving behind 50-60 ml of plasma with platelet.• Platelet is stored at 20-24 degree C, with agitation which causes exchange of gases, maintenance of pH and reduces platelet aggregates and should be used within 5 days.
PLATELET CONCENTRATERANDOM DONORPLATELET(RDP) SINGLE DONOR PLATELETS(SDP)Prep from whole blood donations Prep by platelet pheresis in cellVol-50-60ml separatorPlatelets- 5.5x109/bag or more Vol – 150-300mlRed cells- <1.2x109/bag Platelets – 150-500x 109/bagWhite cells- <0.12x109/bagIt may be supplied as single unitorPooled unit of 4-6 donors
Platelets can be stored in bags made up of Polyvinylchloride(PVC) with Di (2-ethylhexyle) phthalate(DEHP) plasticizer up to 72 hrs at room temp. while certain polyolefin with no plasticizer maintains the platelet function and pH for 7 days. One unit of platelet concentration contains >45x109 platelet, so transfusion of one unit raises platelet count by 5000/microlitre
Plateletpheresis: single donor is connected to the blood separator machine in which whole blood is collected , platelet is separated and retained while rest of component is returned to the donor.This method yields large number of platelet from single donor(6 units of whole blood) upto 30,000-60,000/microlitre
Dosage: As a guide, each unit of random donor platelet should raise platelet in an adult by 5000 to 10000/cumm. 1 unit /10 kg body weight of RDP is required Bleeding, fever, infection, splenomegaly, al loimmunization, and intravascular consumption, each decreases the expected increment. Response to platelet infusions should be continually monitored as essential elements of patient
QUALITY CONTROL(QC)Parameter QC reqd Frequency of controlVol 40-70 ml All unitsPlatelet count >5.5X1010/unit 4 units/monthpH >6.0 -do-Residual 2X109/unit -do-leucocytesRBC Traces-0.5 ml -do- 10
o The usual indications are: • Thrombocytopenia due to decrease in platelet production like aplastic anaemia ,hematologic malignancies ,following radiotherapy or chemotherapy. • or due to increased platelet destruction like ITP, DIC,alloimmune thrombocytopenia, drug induced thrombocytopenia, septicemia. • Heriditary disorders of platelet dysfunction and massive blood transfusion. • Infections like dengue and leptospirosis
o Most of the adverse reaction with platelet transfusion • is due to presence of leucocytes and plasma leading to febrile non-haemolytic transfusion reaction , allergic reaction • Septicemia due to bacterial contamination • Alloimmunisation .
Leucoreduced platelets To minimize the adverse effects of leucocytes present in blood components , the use of leukocyte reduced platelets have been instituted. It can be accomplished by two methods: Filtration Apheresis component programme.
Platelet agitatorPlatelet agitators maintain donor platelets in an even suspension throughout theblood plasma. Platelet agitators are used for storing platelets at a specifiedtemperature range usually between 20 C-24 C
PLASMA COMPONENTS FRESH FROZEN PLASMA (FFP): Plasma is separated from whole blood by centrifugation and is transferred to satellite bag which is rapidly frozen at -80 degree C and then the temp is brought to -18 to -30 deg C. This process is done within 6 hrs. Storage- FFP can be stored for 1yr at -30 degree C and when required should be thawed at 37 degree C .
Contents of 1 unit of FFP prepared from 450ml of whole blood. PLASMA 175 – 250ml Fibrinogen 200 – 400 mgm Rich in factor VIII and I ; Labile factor V DOSAGE: About 5-10 units / kg body weight.
QC of FFPParameter QC Frequency of controlVolume 200-220 plasma 4 units/monthStable 200 units of -do-coagulation each factorfactorsFactor VIII 0.7 units /ml -do-Fibrinogen 200-400 mg -do-
Indications of FFP: ◦ Deficiency of multiple coagulation factors as in liver disease, massive transfusion, DIC . ◦ Familial factor V deficiency ◦ Deficiencies of factor II,VII,IX,X ◦ Antithrombin deficiency ◦ Inherited coagulation factor deficiency.
CRYOPRECIPITATE Cryoprecipitate is prepared from FFP.FFP is kept in the refrigerator upside down at - 30 deg C and then at 4-6 deg C ,FFP melts. This melted FFP moves to another bag,10-20 ml of FFP left is the cryoppt and FFP in other bag is cryo poor plasma. When required for transfusion, cryoppt is thawed at 4 deg C in circulating water bath.
Cryoprecipitate contains factor VIII,von Willebrand factor, fibrinogen, F XIII and fibronectin. The usual dose of cryoprecipitate in treating hypofibrinogenemia is an initial infusion of 10 bags, followed by 10 to 20 bags or as necessary to keep the fibrinogen level above 100 mg/dl. The half-life of fibrinogen is about 4days.
Indications: Used in treatment of Factor VIII deficiency, von Willebrand disease, F XIII deficiency and hypofibrinogenaemia.
CRYO POOR PLASMA This is the supernatant remaining from the production of cryoprecipitate. It is relatively deficient in high molecular weight forms of Von wille brand factor while retaining normal levels of the vWF-cleaving metalloprotease. Use- Treatment of chronic relapsing thrombotic thrombocytopenic purpura.
Liquid plasma Plasma removed from liquid whole blood up to five days after the expiration of the whole blood . Plasma may be stored in the liquid state at I – 60 C.It contains stable clotting factors, however labile clotting factor such as factor VIII and factor V are lost. USE: In deficiency of stable clotting factor(II,VII,IX,X,XI).
Solvent/Detergent treatedplasmaPlasma is treated with the solvent tri(n-butyl) phosphate (TNPB) and the detergent Triton X-IOO to inactivate lipid-enveloped viruses such as hepatitis B and C and HIV. It has no effect on non-enveloped viruses like hepatitis A and parvovirus B 19.
GRANULOCYTECONCENTRATEGranulocyte concentrate is rarely used because: Most infections are controlled with antibiotics. A granulocyte concentrate prepared from a single donor has insufficient granulocyte and contaminated with red cells. Transfusion of granulocyte is associated with significant risks.Granulocyte for transfusion can be obtained single donor unit by differential centrifugation or by leucapheresis.
Leucapheresis is preferred because it yields more granulocyte,which can be further be enhanced by using corticosteroids. Each concentrate contains approximately 10 10 granulocytes which are about one tenth of the normal adult’s daily production and that is far fewer than that of an infected patient. Granulocytes are fragile and may be stored no longer than 24 h. The usual concentrate contains about 250 ml of plasma and has a Hct of 15 to 20 percent. ABO compatibility is necessary.
Indications: Patients with severe neutropenia with documented bacterial or fungal infections. Patients not responding to antibiotics. There is evidence that granulocyte transfusions can benefit a selected group of patients: those with gram-negative sepsis or progressive localized infections, severe granulocytopenia, and temporary suppression of leukocyte production.
BLOOD DERIVATIVES HUMAN ALBUMIN-- Comprised of 96% albumin and 4%alpha and beta–globulin.-- Prepared by cold fractionation of pooledplasma.
INDICATIONS -- Used as replacement fluid in therapeutic plasma exchange and treatment of diuresis resistant edema. -- In hypovolemic shock, hypotension associated with hypovolemia in liver failure or protein losing conditions.
FACTOR VIII CONCENTRATE -- Prepared by fractionation from large pools of plasma -- Heat treated to eradicate any HIV or hepatitis virus contaminants. -- Available in freeze-dried forms INDICATIONS: -- Hemophiliacs -- severe Von Willebrand’s Disease
FACTOR IX CONCENTRATE-- Both plasma derived and recombinantfactor IX concentrates are available.INDICATIONS:-- Hemophilia B
PROTHROMBIN COMPLEX CONCENTRATE-- Combination of blood clotting factors II,IX,X and sometimes factor VII as well as protein C and S. INDICATIONS:-- Inherited deficiency of factor IX,X or II-- Hemophilia A with inhibitor antibodies against factor VIII and who are non responsive to factor VIII concentrate.
IMMUNOGLOBULINS-- Prepared by cold ethanol fractionation of pooled plasma.-- They are of two main types: Non- specific immunoglobulins -- Prepared from pooled plasma of non- selected donors -- Composed of antibodies against infectious agents prevalent in the donor population
INDICATIONS:-- Passive prophylaxis against hepatitis A.-- Congenital or acquired hypogammaglobulinaemia .-- Autoimmune thrombocytopenic purpura to raise platelet count.
Specific immunoglobulins-- Prepared from donors who have specific high titer IgG antibodies. INDICATIONS:-- Specific immunoglobulin for passive prophylaxis against hepatitis B,varicella zoster,cytomegalovirus,or tetanus.-- Anti-RhD immunoglobulin used for prevention of immunization against RhD antigen in RhD-negative mothers during pregnancy.
RECENT ADVANCES Semi automated methods Methods for Apheresis ◦ Manual method ◦ Automated methos Pharmacological products as alternative to blood components.
Semi automated methods: ◦ Preparation of L-R cells concentrate ◦ Preparation of platelet from buffy coat OPTIPRESS: automatic extractor having two plates,one is stationary and other expels plasma in empty satellite bag and red cells into bag containing SAGM.
OPTIPACKS:•Contains one 600ml bagmade up of PVC having63ml CPD phlebotomyneedle is attached. thisbag is connected to two400ml bags ,one forcollection of plasma andthe other platelets whichcan be stored for 5 days .
APHRESIS Apheresis is collection of anti-coagulated whole blood from a donor, its separation into components, retention of desired component and return of remaining constituents back to the donor with the help of automated cell separator machines.
ADVANTAGES OF APHRESIS Reduced multiple donor exposure ◦ Reduced risk of alloimmunization ◦ Reduced incidence of transfusion transmitted diseases Full and effective transfusion dose Purer product: ◦ leucocyte reduced products High quality product Fewer donor reaction due to return of fluid
Types of cell separatorsIntermittent flow cell separator (closed system)Continuous flow cell separatorAutomated separation techniques by centrifugationCell separation by membrane filtration Continuous magnetic cell separator (immunomagnetic)
Automated separation technique by centrifugation: ◦ Centrifugal force separates blood into different component depending upon the specific gravity. ◦ Blood is drawn from an automatic pump Anticoagulant is added to the tube and blood is pumped into rotating bowl chamber in which layering of components occurs based on the density. The desired component is retained and rest returned to donor either by continuous flow or by intermittent flow.
Separation by Membrane Filtration: ◦ Filtration of plasma through membrane which allows collection of plasma from a healthy donor. ◦ Membranes are arranged as hollow fibres which expels the cellular elements in the flow of blood. ◦ Most commonly used apheresis devices are: Haemonetic corporation: Platelets, plasma, leucocytes. Baxter: Plasma, platelets, red cells, leucocyte Gambro: Plasma, platelets, leucocyte and peripheral blood stem cells.
HAEMONETIC: It is intermittent centrifuge separator. The anticoagulated blood is pumped into rotating bowl .This incoming blood is separated.The red cells move to the periphery and plasma to inside of rotating bowl and the white cells and plasma between red cells and plasma. Using optical detectors and fluid surge elutriation process,the desired component is retained.
GAMBRO(Cobe) Continuous flow centrifuge cell separator where two arm blood is drawn and returned. Here flat membrane is used to separate the cells of blood from plasma. Allows lower WBC and RBC contamination in platelets.
BAXTER Continuous flow technology. CS 3000 has two separation containers firstly for collection of leucocytes reduced platelets and other for white cells (CS 3000 plus).
REFERENCES DGHS Manual of blood transfusion 2003 Essential of clinical Haematology – Shirish M kawathalkar INTERNET