blod transfusion- introduction , procedure , pre transfusion tests , complications , characteristics of components and components usually used like packed red cells, FFP, platelet rich plasma, cryoprecipitate, albumin and other plasma derivatives

2. Blood transfusion is the transfusion of whole blood or its components from one
person to other person.
At present almost all transfusions are in the form of transfusion of components
Important components of blood that are frequently used include
• Packed red cells
• Platelets
• Fresh frozen plasma
• Cryoprecipitate
• Albumin
• Plasma derivatives

3. whole blood
a unit of whole blood consists of 450ml +/- 10% of blood
from a suitable donor plus 63ml of anticoagulant which is
then leucocyte depleted.
It is ideal component for patients who have sustained acute
hemorrhage of >25% total blood volume loss.
Stored at 4ºC is given a shelf life of 5 weeks,when atleast
70% of the transfused red cells should survive normally
Whole blood is now rarely used for transfusion

4. PACKED RED CELLS
 Used when primary aim is to increase the oxygen carrying capacity of
blood
 Can improve platelet function particularly in uraemic pts
 1 unit of RBC can be expected to result in raise of Hb of 1gm/dl in an
adult.

5. Packed red cells
 INDICATIONS
 Symptomatic anaemia in a euvolemic pt. in bleeding pt replacement of
intravascular volume is the first priority
 Hb < 7gm/dl in a critically ill pt with a target Hb of 7-9 gm/dl unless
specific comorbidities or acute illness related factors modify clinical
decision making
 HB<8 or 9 gm/dl in acute MI,CHF,Angina,TIA and syncope . Target hb is
>9gm/dl
 Hb <8gm/dl in pts with stable angina and thalassaemia.
 Hb <10 gm/dl in pts with uraemic bleeding

6. PLATELET RICH PLASMA
 Required when bleeding occurs either due to reduced platelets or
inadequate platelet function.
 1 PRP bag generally inc platelet count by 4000-8000/㎣
 Because platelets express the same A and B antigens as RBC , it is best to
issue platelets that are compatible with the recepients’ naturally
occuring anti-A or anti-B antibodies
 Platelets can also be derived from single donor [ single donor platelets
,SDP]
 Apheresis platelets are indicated for pts with immune refractoriness
when crossmatched or HLA matched platelets have better post
transfusion survival

7. Indications for PRP
 Microvascular bleeding due to thrombocytopenia and platelet dysfunction.
 Prophylactic platelet transfusion may be indicated if platelet count is <10,000/㎣
. A higher threshold may be appropriate for pt with high fever,
hyperleucocytosis, rapid fall in platelet count and coagulopathy
 Surgical or invasive procedures in thrombocytopenic pts.
 In pts with autoimmune thrombocytopenias, platelet transfusion should be
reserved for pts with life threatening bleeding.
CONTRAINDICATIONS
 In thrombocytopenic purpura and in heparin induced thrombocytopenia
 Relatively contraindicated in idiopathic thrombocytopenic purpura or post
transfusion purpura because the survival of transfused platelets is extremely
brief

8. FRESH FROZEN PLASMA
• it contains all coagulation factors including von willebrand factor
• Plasma contains antiA and antiB antibodies depending upon blood
groups . Pt should only receive plasma which doesn’t contain an
antibody which would attack their own red cells
• Rh Compatibility is not required
• As FFP is not concentrated plasma, volume overload may occur if
requirements are high.
• A dose of 10ml/kg will typically provide sufficient coagulation factors to
achieve hemostasis.

9. Fresh frozen plasma
• INDICATIONS
• Single coagulation factor deficiency particularly V and XI deficiency.
• Consumptive coagulopathies such as DIC
• Dilutional coagulopathy due to massive transfusion
• Cogulopathy of liver disease
• Microangiopathic hemolytic anaemia including TTP , HUS, and HELLP
syndrome
• Reversal of warfarin anticoagulation

10. CRYOPRECIPITATE
 Concentrate of factor VIII , von willebrand factor, fibrinogen and factor XIII
 Each unit contains a minimum of 80 units of factor VIII and typically 250mg of
fibrinogen
 Doesn’t require crossmatching before transfusion
 INDICATIONS
 Factor VIII deficiency when factor VIII concentrate is not
available
 Vonwillebrand disease
 Hypofibrinogenaemia with fibrinogen <100mg/dl
 Factor XIII deficiency
 Some evidence suggests that cryoprecipitate transfusion can decrease
bleeding due to uraemic platelet dysfunction

11. ALBUMIN
 2 Preparations are available - human albumin soln 4.5% and human
albumin soln 20%
 INDICATIONS
 For treatment of acute severe hypoalbuminaemia and as the
replacement fluid for plasma exchange
 20% albumin soln is particularly useful for pts with nephrotic
syndrome or liver disease who are fluid overloaded and resistant to
diuretics
 Albumin soln shouldn’t be used to treat pts with malnutrition or chr
renal or liver disease who have low serum albumin

12. Plasma derivatives
Plasma from thousands of donors may be pooled to derive
specific protein concentrates including albumin, IV
immunoglobulin, antithrombin and coagulation factors
in addition donors who have high titre antibodies to
specific agents or antigens provide hyperimmune globulins
such as anti D and antisera to hep-B virus, varicella zoster
virus, CMV and other infectious agents

14. PRETRANSFUSION TESTING
 BLOOD GROUPING
 The ABO and Rh-D groups of the pt are determined
 ANTIBODY SCREENING
 The pt’s serum or plasma is screened for atypical antibodies that may cause
significant reduction in survival of transfused red cells
 The pt’s serum or plasma is tested against redcells from atleast 2 group O donors
expressing a widerange of redcell antigens for detection of IgM redcell
alloantibodies
 About 10% of pts have positive antibodies screening result.in this case further test
is carried out using a comprehensive panel of typed red cells to determine the
bloodgroup specificity of antibodies

15. Selection of donor blood and cross matching
 Selection procedures: donor blood of same ABO and RhD group as
the pt is selected. Matching for additional bloodgroups is carried out
for pts with clinically significant red cell antibodies and who are likely
to be multi transfused and high risk of developing antibodies
 Crossmatching procedures: conventional crossmatching consists of
the group and antibody screen followed by direct confirmation of
compatibility of individual units of redcells with pt’s serum
 Blood can be supplied by electronic issue without the need for
compatibility crossmatching if the laboratories’ computer system
shows the pts ABO and RhD groups have been identified and
confirmed on 2 separate occasions and their antibody screen is
negative.

16.  450 ml of whole blood + 63 ml of anti coagulant or preservative
 process into blood components
 Filter to remove leucocytes
Redcells
Stored at 4ºC
35 days
Fresh frozen plasma
Stored at -30ºC
24 months
Pooled/apheresis
platelets
Stored at 22ºC
5 days

18. COMPLICATIONS OF BLOOD TRANSFUSION
IMMUNOLOGICAL REACTIONS
Acute hemolytic transfusion reaction: occurs due to transfusion of
incompatible donor red cells.
Clinical features: early features are fever, chills,
backpain,pruritus,burning sensation at the site of transfusion and
centrally along the vein and chest pain
• In an unconscious pt, more severe features like
hypotension,shock,hemoglobinuria,oliguria and excessive bleeding
due to DIC develop

19. management
 Stop the transfusion immediately if a transfusion reaction is suspected
 Change the blood transfusion set and maintain the venous access using normal
saline
 Perform physical examination with spl attention to BP, urine output, and
evidence of bleeding
 Withdraw blood samples from the opposite arm . Send one sample to the
bloodbank for evaluation and centrifuge the other sample to look for any free
Hb in the supernatant
 Get a coagulation screen including partial thromboplastin time , platelet count ,
fibrinogen level , fibrin degradation products to exclude DIC
 If hypotension develops, administer fluids and if required vasopressors
 Administer furosemide to maintain urine output

20. FEBRILE NON HEMOLYTIC REACTION
 Generally occur due to anti leucocyte antibodies in a pt who has been
pregnant or has been previously transfused , reacting against
leucocytes in the transfused blood.
 Can also occur due to cytokines in stored platelet concentrates
 Generally occur towards the end of infusion or within hrs of
completing the transfusion
 Management is symptomatic with antipyretics
 Incidence can be reduced by leucoreduction in which WBCs are
reduced in no. through centrifugation or filtration.

21. URTICARIA: due to the presence of antibodies in the recepients
blood to infused plasma proteins or infusion of allergens that react with
IgE antibodies in the pt
ANAPHYLAXIS: Occurs in pts who have antibodies against IgA and
are often deficient in IgA. The antibodies react with IgA present in the
donor blood
TRANSFUSION RELATED ACUTE LUNG INJURY [TRALI]
 The donor plasma has antibodies to pts leucocytes .such antibodies are
found most frequently in females after pregnancy and are not present
plasma of males unless the have been transfused
 Pt develops an acute resp rxn with fever, cough, shortness of breath
typical appearance on chest X-ray. The rxn occurs during or soon after
transfusion and may be life threatening

22. DELAYED HEMOLYTIC TRANSFUSION REACTION
 It occurs 3 to 21 days after transfusion with the incompatible blood
 Pt as IgG antibodies to the red cell antigens such as Rh,Kidd, kell,
Duffy because of previous pregnancies or transfusion. The
antibodies are undetectable during crossmatch but further
transfusion causes a secondary immune response resulting in
delayed hemolysis
 Direct coomb’s test will be positive if carried out while the pt is
actively hemolysing. Later only indirect coombs test may be positive

23. TRANSFUSION ASSOCIATED GRAFT VERSUS HOST DISEASE
[TA-GVHD]
 It occurs due to immune rxn of donor T-cells against the recepient who is
often immunodeficient , example: bonemarrow allograft recepient ,
hodgkins lymphoma
 Clinically pt develops fever , skin rash, liver and renal failure and
pancytopenia. It develops 4-30 days after transfusion and may be fatal
 Prevention is by using gamma irradiation of cellular blood components

24. POST TRANSFUSION PURPURA
 It is an immune mediated thrombocytopenia that usually occurs in
parous females
 Antibodies against human platelet antigens [HPAs] are detectable in
the pt’s serum
 It occurs 5 to12 days after transfusion
 Thrombocytopenia is usually severe and may cause bleeding
 Platelet transfusions are usually ineffective and the treatment of
choice is a high dose intravenous immunoglobulins[0.4g/kg/day for
days]

25. NON IMMUNE REACTIONS
 Transfusion associated circulatory overload[TACO], especially in pts
with renal and cardiac failure – blood components are excellent
volume expanders.
 ELECTROLYTE TOXICITY
 Hyperkalemia –occurs due to RBC leakage during storage
 Citrate toxicity – due to commonly used anti coagulants
 Iron overload – symptoms appear after 100 units of RBCs have
been transfused.
 HYPOTENSIVE REACTIONS- in pts taking ACE inhibitors
 Air and fat embolism
 Thrombophlebitis

26. Infectious complications
 viral infections: HIV type1 , HBV, west nile virus, CMV, HTLV Type 1,
parvovirus
 Bacterial infections: Yersinia, pseudomonas, serratia, acinetobacter
and escherichia species
 Other infectious diseases: malaria, babesiosis, chaga’s disease
 other agents implicated in transfusion include dengue , chikun gunya
virus , variant creutzfeldt jacob disease.

27. INVESTIGATIONS AND MANAGEMENT
OF REACTIONS TO BLOOD PRODUCTS

28.  If transfusion reaction is mild fever,
 Febrile non hemolytic transfusion rxn:
 If isolated temp is >38ºC, or raise of 1-2ºC , observations are stable
and the pt is otherwise well- give paracetamol, restart infusion at a
slower rate and observe more frequently
 If it is urticaria
 Mild pruritus/rash
 Give chlorphenamine 10mg slowly IV and restart transfusion at a
slower rate and observe more frequently

29. SUSPECTED ABO INCOMPATIBILITY
 May be due to wrong blood pack infused or hemoglobinuria
 ABO incompatibility- take down the unit and given set and return intact to
blood bank
 Commence IV saline infusion, monitor urine output / catheterise
 Maintain urine output at >100 ml. give furosemide if urine output falls
 Treat DIC with appropriate blood components
 inform hospital transfusion department immediately

30. Severe allergic reaction
 Give chlorphenamine 10mg slowly i.v
 Commence O2 and fluid support
 Give salbutamol nebuliser
 If severe hypotension or bronchospasm give adrenaline
0.5mg i.m

31. BACTERIAL CONTAMINATION
 Blood pack discolored or damaged
 Rapid onset of hypo or hypertension, rigors and collapse
• Take blood cultures ,repeat cross matching biochemistry urine
analysis
• Monitor urine output
• If bacterial infection is suspected broad spectrum antibiotics are
given
• Commence oxygen and fluid support

32. If acute dyspnoea or hypertension
 Monitor blood gases
 Perform chest x-ray
 Measure central venous or pulmonary capillary pressure
 If raised cvp it may be due to fluid overload
• Give O2 and furosemide 40 – 80mg i.v
 If normal cvp it may be transfusion related acute lung injury
 Discontinue transfusion
 Give 100% O2
 Treat as ARDS – ventilate if severely hypoxaemic

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