Blood transfusion can cause both immune-mediated and non-immune complications. Immune reactions include acute hemolytic transfusion reactions caused by ABO incompatibility, delayed hemolytic reactions, febrile non-hemolytic reactions, allergic reactions, graft-versus-host disease, and transfusion-related acute lung injury. Non-immune risks are fluid overload, hypothermia, and electrolyte toxicity such as hyperkalemia. It is important to carefully match blood type and screen for antibodies to prevent immune complications of transfusion.

1. Blood Transfusion &
Blood Component Therapy
Prof.(Dr.) Annasaheb. J. Dhumale.
Head of Department of Medicine,
Chief Medical Oncologist & Haematologist,
Shri Shankaracharya Institute of Medical Sciences
Bhilai (C.G).INDIA.PIN-490020
drajdhumale@gmail.com

2. Blood group system
&
Pre-transfusion testing

3. ABO blood group system
•1st system discovered in 1900 by Karl Landsteiner
•Gene on chromosome 9p and inherited in Mendelian co-dominant manner
•What is “Bombay” blood group ???
Blood Group Antigen on RBC Antibody in plasma
O None Anti A and Anti B
A A Anti B
B B Anti A
AB A and B None

4. The Rh blood groupsystem
•2nd most importantsystem
•Gene on chromosome 1
•The presence of D antigen confers Rh positivity
•15% lack this antigen
•Exposure of Rh- recipients to Rh+ cells results in production of anti-D antibodies

5. Other blood groupsystems
•More than 100 systems recognised, composed of more than 500 antigens
•Clinically significant systems are
1. Kelly, Kidd & Duffy system
2. MNS system
3. Lewis & P system
4. I/i system

6. Pre-tranfusion testing
Two stages – “type & screen”
1. Forward type
◦ Determine ABO & Rh phenotype of recipient RBC
◦ Antisera against A, B & D antigens used
2. Reverse type
◦ Determine the antibodies: anti-A, anti-B & anti-D in patient’s serum
◦ Should correlate with ABO phenotype

7. Cont…
1. Antibody screen
◦ Determine antibodies in patient’s serum directed against other RBC antigens
◦ Type O RBC (containing major antigens of most blood groups) is mixed with patient’s
serum
2. Cross-matching
◦ Performed after antibody screen, when the antibodies in patient’s serum are
recognised
◦ Blood selected for cross matching should be ABO compatible and lack the antigens
for which patient has antibodies

8. Bedside procedure for safe transfusion

9. Blood Components

10. Whole Blood
•450 ml donor blood collected as “whole blood” into 63 ml CPDA-1 (citrate
phosphate dextrose adenine) as anticoagulant preservative
•Hematocrit is 30-40%
•Stored at 4°C
•At this temperature, platelets lose viability, granulocytes disintegrate and labile
coagulation factors decline
•Indication: acute hemorrhage with >25% blood loss
•Provide both oxygen carrying capacity & volume expansion

11. Blood component separation

12. Blood components

13. Packed Red Cells (PRC)
13

14. Indications for PRC transfusion
•Blood volume loss : > 30%
•Hb % : < 8 gms
Response :
One unit increases Hb% by 1gm%
OR
PCV (Hct) by 3%
( response best seen > 24 hrs)
14

15. Guidelines for PRC transfusion
Purpose of packed red cell transfusion is to restore
O2 delivery to tissues
• Fully matched blood – most preferred
In case of emergency & non-availability
•Group O Rh –ve cells
OR
•Group specific uncrossmatched blood
15

16. Packed red blood cells
•Volume is 180-200 ml
•Shelf life of 35 days at 4°C
•Hematocrit is 65-75%
•1 unit PRBC raises Hb by 1 g/dL or Hct by 3%
•Increases oxygen carrying capacity in anemic patients but without volume
expansion
•Transfusion threshold is 7 g/dl in normovolumic patients without cardiac disease
and comorbid conditions
•In critical patients, Hb target is 10 g/dl

17. Platelet concentrates
17

18. Platelets
•Random Donor Platelets (RDP)/ pooled platelets:
prepared from whole blood by centrifugation
•Single Donor Platelets (SDP)/ jumbo platelets:
prepared by plasma apheresis machine
•Volume of RDP is 50-70 ml & SDP is 200-400 ml
•Shelf life of 5 days at 22°C

19. Blood component separation

20. Platelet concentrates - RDP
•Separated from single blood unit
•Volume : 50 ml/unit
•Preparation time : 1 hour
•Storage : 20 -24 degree Celsius on agitator
•Shelf life : 5 days
•1 unit of RDP increases platelet count by 6,000-8,000 cells /
cumm

22. Platelet concentrates - SDP
•Only platelets are obtained from single donor by Apheresis
•Volume : 200 - 400 ml/unit
•Preparation time : 24 - 48 hours
•Storage : 20-24 degree Celsius on agitator
•Shelf life : 5 days
•1 unit of SDP increases platelet count by 30,000-60,000
cells/cumm
22

23. Platelet concentrates
Advantages of SDP :
•Fewer donor exposure
•Bacterial contamination reduced by 10%
•Septic transfusion reaction reduced by 5 fold
Disadvantages of SDP :
•Not readily available for emergency purpose
•Higher processing fee
23

24. Indications for Platelet concentrates
•Without evidence of bleeding Platelet count
less than 20,000 / cmm
•With evidence of bleeding / DIC Platelet count < 50,000/
cmm
Dose :
6-8 units RDP or 1 unit SDP should be transfused over a
period of 30 minutes immediately after issue.
24

25. Guidelines for platelet transfusion
•To be transfused immediately after issue and completed
within 20 minutes
•Do not transfuse platelets with transfusion set previously
used for red cells
•Always use a fresh IV set for platelet transfusion
25

26. Guidelines for platelet transfusion
•Essential for platelet Concentrates to be ABO & Rh
specific
•If tranfused, ABO-incompatible platelets may have a
shorter life span
•Rh compatibility should be considered in the obstetric
population and Anti D Rh immune globulin should be
administered if Rh-positive platelets are administered
26

27. Platelets cont…
•1 unit of SDP = 6 units of RDP
•1 RDP increases platelet count by 5000-10000, in unsensitised patient without
increased platelet consumption (DIC, splenomegaly, fever)
•Threshold for prophylactic platelet transfusion is 10000
•If patient is without fever or infection (eg ITP), a threshold of 5000 is sufficient
•For invasive procedures & surgeries, platelet target is 50000

28. Fresh Frozen Plasma ( FFP)
28

29. Fresh frozen plasma
•FFP contains coagulation factors & plasma proteins - albumin, fibrinogen, anti-
thrombin, protein C & S
•Volume is 200-250 ml
•Shelf life of >1 year at -30°C, if thawed can be stored for 24 hr at 4°C
•Indications are coagulation disorders like DIC, liver diseases, congenital bleeding
disorders & reversal of warfarin therapy
•Doze is 10-15 ml/kg body weight
•1 unit FFP raises coagulation factors by 2%
•Transfusion monitored by PT/INR, stopped when INR <1.5

30. Indications for FFP transfusion
•Lab confirmed diagnosis of DIC with or without bleeding
•Empirically when DIC is strongly suspected in an actively
bleeding patient
30

31. Goals of treatment with FFP
•Maintain fibrinogen level above 100 mg /dl
•Maintain PT and APPT less than 1.5 times control values
•Stop persistent active bleeding
31

32. Cryoprecipitate
32

33. Cryoprecipitate
•15-20 ml per unit of Cryoprecipitate contains fibrinogen,
factors 5, 8 & 13 and VW factor
•Storage : -25 degree Celsius or colder
•Dosage : 5-10 units
OR
1 unit/ 10 kg body weight
33

34. Cryoprecipitate
•Issued by blood bank after thawing for
20-30 minutes
•Shelf life : 4–6 hours after thawing
12 months frozen
•Transfuse as soon as possible after issue and completed
within 20 minutes
•1 unit of Cryoprecipitate increases the fibrinogen level by
5-10 mg%
34

35. Indications for Cryoprecipitate
•It contains fibrinogen, factor VIII & von Willebrand factor
•(1 unit cryoprecipitate contains 80 units of factor VIII)
•Indications:
•1. DIC (serum fibrinogen <100mg/dl),
•2. Haemophilia A (poor countries) and
•3. Von Willebrand disease
35

36. Granulocytes
•Harvested from donors by apheresis after stimulation by G-CSF &
dexamethasone
•Indicated in febrile neutropenia (ANC<500)

37. Plasma derivatives
•Specific protein concentrates including albumin, intravenous immunoglobulin,
anti-thrombin, and coagulation factors
•Hyperimmune globulins such as anti-D, and antisera to hepatitis B virus (HBV),
varicella-zoster virus, CMV & other infectious agents

38. General guidelines for Blood Component
Transfusion
•Do not give blood & blood components unless it is a life
saving measure
•Take informed written consent
•Double check patient identification details, grouping,
cross matching & screening tests and expiry date
•Use sterile, pyrogen free, disposable & appropriate
infusion sets
38

39. General guidelines for Blood
Component Transfusion
•ABO incompatibility errors – major & life threatening
• Patient misidentification, Sample mislabeling and laboratory
errors
• Vigilance is required by all personnel
involved in blood product administration
39

40. General guidelines for Blood Component
Transfusion
Even in the emergency situations
Protocols for the checking and administration of
blood must be adhered to as most transfusion
related morbidity is due to incorrect blood being
transfused
40

41. General guidelines for Blood Component
Transfusion
•Keep all the emergency drugs ready
•Warming of blood not required except in situations of
massive transfusion
•Do not add any drugs or give any medication along with blood
/ component therapy ( only NS allowed)
41

42. General guidelines for Blood Component
Transfusion
•Monitor and document patient’s Vitals before, at
start, during ( every 15 minutes) , at end & for
2 - 4 hours after transfusion
Other documentation required ;
•Time - start & completion
•Type & units of components
•The unique donation number of components
•Any adverse reactions
42

43. Recent Advances-rFVIIa
Recombinant activated factor VII (rFVIIa) is
synthesized human factor VII that is available for
reconstitution and infusion in patients with massive
hemorrhage.
Decrease in RBC requirement ,a trend toward
improved survival and reductions in critical morbidities.
Thrombosis ??
Dosing guidelines for h’ge (general range, 90-120
mcg/kg of body weight) have yet to be established
Cost of rFVIIa is over $3000 / patient
Dr Mona Shroff www.obgyntoday.info 43

44. Artificial Blood
Two main categories of oxygen carrying blood substitutes
1. Hemoglobin based oxygen carriers
2. Perfluorocarbon based oxygen carriers
•In trial stage

45. Types of Replacement Products under research
Oxygen Carrying Solutions
Hemoglobin Based Oxygen Carrying Solutions
(HBOCS)
Perflourocarbons
Other
Antigen Camouflage
Recombinant Plasma Proteins
Transgenic Therapeutic Proteins
Platelet Substitutes
Dr Mona Shroff www.obgyntoday.info 45

47. Complications
of
Blood Transfusion

48. Adverse reactions to blood transfusion
1. Immune-mediated reactions are due to preformed donor or recipient
antibody, however cellular components of stored blood may also cause
immune reactions
2. Non-immune reactions are due to the chemical and physical properties of
stored blood components and its additives like anticoagulant. It include
infections complications

50. Risk of transfusioncomplications

51. IMMUNE-MEDIATED REACTIONS

52. Acute Hemolytic Transfusion Reactions
Mechanism: The recipient has preformed antibodies that lyse donor RBC
The ABO alloantibodies are responsible for the majority, however, alloantibodies
against other RBC antigens, Rh, Kell, and Duffy are associated with more fatal
reactions
Presentation: Hypotension, tachypnea, tachycardia, fever, chills,
hemoglobinuria, chest pain, flank pain, and discomfort at the infusion site

53. AHTR Cont...
Management:
▪When suspected, stop transfusion immediately.
▪Direct Coombs test detects the antibody bound to RBC
lactate dehydrogenase, and▪Hemolysis studies including serum haptoglobin,
indirect bilirubin levels
▪Hemolysis causes renal dysfunction. Give intravenous fluids to induce diuresis
▪Tissue factor released from lysed erythrocytes may initiate DIC. Coagulation
studies including PT, aPTT, fibrinogen, and platelet count

54. Delayed Hemolytic Transfusion Reactions
Mechanism: These patients are previously sensitized to RBC antigens, but have
low antibody levels and negative antibody screen. When re-transfused with the
same antigen, memory response results in early production of antibody (1–2
weeks after transfusion)
The transfused, antibody-coated RBC are removed by the reticuloendothelial
system
Presentation: Mild reaction
Management: No specific therapy is usually required

55. Febrile Non-hemolytic TransfusionReaction
The most frequent blood transfusion reaction
Mechanism: Antibodies directed against donor WBC, and Cytokines released
from cells within stored blood components
Presentation : Fever with chills and rigors
Management: Use leukocyte-reduced blood products

56. Allergic Reactions
Mechanism: Allergy to plasma proteins in transfused components
Presentation: Urticaria, pruritus, anaphylaxis
Management: Stop transfusion temporarily and administer antihistamines,
corticosteroids if severe.
Prevention: Cellular components washing to remove residual plasma

57. Graft-Versus-Host Disease
Mechanism: Donor T lymphocytes recognize recipient's HLA antigens as foreign
and mount an immune response
Presentation: Fever, cutaneous eruption, diarrhea, and liver function
abnormalities
Management: Resistant to immunosuppressive therapies. Clinical
manifestations appear at 8–10 days, and death occurs at 3–4 weeks
Prevention: Irradiation of cellular components before transfusion

58. Transfusion-related acute lung injury (TRALI)
TRALI is the most common cause of transfusion related fatalities
Definition: TRALI is defined as an acute lung injury (PaO2/FiO2 <300 mmHg) that
is temporally related to a blood transfusion; specifically, it occurs within the first
six hours following a transfusion
Mechanism: The donor anti-HLA class II antibodies bind recipient neutrophils,
these neutrophils aggregate in pulmonary vasculature and release inflammatory
mediators that increase capillary permeability

59. TRALI Cont...
Risk factors: Smoking, chronic alcohol use, shock, liver surgery, mechanical
ventilation and positive fluid balance
Presentation: Symptoms of hypoxia (PaO2/FiO2 <300 mmHg) and signs of non-
cardiogenic pulmonary edema, including bilateral interstitial infiltrates on chest
x-ray
Management: Supportive

60. Chest X-rayof
TRALI...
Bilateral interstitial
infiltrates

61. Post-transfusion Purpura
Mechanism: Anti-platelet antibodies are produced that react to both donor and
recipient platelets
Presentation: Delayed thrombocytopenia 7–10 days after platelet transfusion
Management: Intravenous immunoglobulin to neutralize the antibodies, or
plasma exchange to remove the antibodies

62. NON-IMMUNOLOGIC REACTIONS

63. Fluid Overload
▪Blood components are excellent volume expanders, and transfusion may quickly
lead to transfusion-associated circulatory overload (TACO)
▪Dyspnea with SpaO2 <90%, bilateral infiltrates on chest x-ray, and systolic
hypertension are found with TACO
▪Monitoring the rate and volume of transfusion and using a diuretic can minimize
this problem

64. Hypothermia
▪Refrigerated (4°C) or frozen (−18°C or below) blood components when rapidly
infused
▪Cardiac dysrhythmias on exposure of the SA node to cold fluid
▪An in-line warmer will prevent this complication

65. Electrolyte Toxicity
Hyperkalemia:
•RBC leakage during storage increases the potassium concentration in blood unit
•Prevented by using fresh or washed RBCs in high risk patients like renal failure
Hypocalcemia:
•Citrate, used as anticoagulant, chelates calcium and inhibits coagulation
•Hypocalcemia manifest by circumoral numbness and tingling sensation of
fingers and toes

66. Iron Overload
▪Each unit of RBCs contains 200–250 mg of iron
▪Symptoms and signs appears after 100 units of RBC transfusion (total-body iron
load of 20 g)
▪Prevent by using alternative therapies (eg erythropoietin in CKD) and judicious
transfusion
▪Chelating agents, such as deferoxamine and deferasirox, used but response is
often suboptimal

67. Immunomodulation
▪Transfusion of allogeneic blood is immunosuppressive.
▪Transfusion-related immunomodulation is thought to be mediated by
transfused leukocytes.
▪Leukocyte-depleted cellular products may cause less immunosuppression

68. INFECTIOUS COMPLICATIONS

69. National blood safety policy
Testing for every unit of blood is mandatory for
1. HIV
2. Hepatitis B
3. Hepatitis C
4. Malaria
5. Syphilis

70. Viral contamination
1. Hepatitis C (HCV): antibodies to HCV and HCV RNA.
2. Human immunodeficiency virus (HIV): antibodies to HIV, p24 antigen and
HIV RNA
3. Hepatitis B (HBV): HbsAg antigen
4. Other Hepatitis viruses
5. West Nile virus
6. Cytomegalovirus (CMV)
7. Human T lymphotropic virus (HTLV) type 1
8. Parvovirus B19

71. Bacterial Contamination
▪Most bacteria don’t grow well at cold temperatures, hence not common with
PRBC and FFP. However, some gram-negative bacteria can grow at 1–6°C, eg
Yersinia, Pseudomonas, Serratia, Acinetobacter and Escherichia species
▪Platelet, stored at room temperature are more likely to contain skin
contaminants eg coagulase-negative staphylococci
▪Presentation: Fever and chills, which can progress to septic shock and DIC
▪Treatment: stop transfusion immediately if suspected, manage shock and give
broad-spectrum antibiotics
▪Sent blood component bag for culture and Gram stain

72. Other Infectious Agents
Various parasites, including those causing malaria, babesiosis, and Chagas’
disease and syphilis can be transmitted by blood transfusion

73. Massive Blood
Transfusion

74. Massive Blood Transfusion Definition
The replacement of one blood volume (equivalent to 10 units of blood) in any
24 hour period,
or
Half of the blood volume (5 units of blood) in four hour period in an adult

75. Massive transfusion indications
1. Severe trauma
2. Ruptured aortic aneurysm
3. Vascular/aortic surgeries
4. Obstetric complications

76. Massive Transfusion Protocol
These parameters should be measured frequently (every 30‐60 minutes, or
after transfusion of blood component).
1. Temperature
2. Acid‐base status
3. Ionised calcium (Ca)
4. Haemoglobin
5. Platelets (Plt)
6. PT/APTT (activated partial thromboplastin time)
7. Fibrinogen

77. Mortality
Mortality is high in massive transfusion
Its etiology includes hypotension, acidosis, coagulopathy, shock and underlying
condition of the patient
The lethal triad of acidosis, hypothermia and coagulopathy have the highest
mortality rate
It is often the underlying cause and consequences of major hemorrhage that
result in complications, rather than the transfusion itself

78. Complications of Blood Transfusion▪ Metabolic complications
 Hyperkalaemia
 Citrate toxicity & hypocalcaemia
 Release of vasoactive peptides
 Release of plasticizers from PVC-phthalates
▪ Haemorrhagic reactions
 After massive transfusion of stored blood
 Disseminated intravascular coagulation
▪ Transmission of disease
 Hepatitis, CMV. EBV
 AIDS (Factor VIII)
 Syphilis
 Brucellosis
 Toxoplasmosis
 Malaria
 Trypanosomiasis
Febrile reactions
Bacterial contamination
Immune reactions
Physical complications
• Circulatory overload
• Air embolism
• Pulmonary embolism
• Thrombophlebitis
• ARDS

79. Adverse reactions of Blood Transfusion
Mild
•Symptoms - pruritis
•Signs - localised cutaneous reactions
Urticaria, rash
✓Action - Stop transfusion
Give –
Inj. Promethazine 10 mg IV &
Inj. Hydrocortisone 100 mg IV
re ensure grouping & compatibility
continue transfusion if patient is asymptomatic

80. Adverse reactions of Blood Transfusion
Moderate
•Symptoms -
pruritis, anxiety,
palpitations,
dyspnoea, head ache
•Signs -
flushing, urticaria, rigors,
fever, tachycardia,
restlessness

81. Adverse reactions of Blood Transfusion
Moderate
✓ Action
•Stop transfusion
•Give Inj. Promethazine 10 mg IV &
Inj.Hydrocortisone 100 mg IV
•Inj. Aminophylline 250mg IV, if broncospasm
• re ensure grouping & compatibility
•Donot restart same transfusion

82. Adverse reactions of Blood Transfusion
Severe
•Symptoms - anxiety, chest pain,
pain at the transfusion site,
severe dyspnoea, head ache,
loin / back pain
•Signs - rigors, fever, tachycardia,
restlessness, Hypotension,
unexplained bleeding

83. Adverse reactions of BloodTransfusion
Severe
✓Action
• Stop transfusion
•Give -
Inj. Promethazine 10 mg IV &
Inj. Hydrocortisone 100 mg IV
Inj. Aminophylline 250mg IV if broncospasm
•shift the patient to critical care unit for
multidisciplinary mangaement
• re ensure grouping & compatibility

84. Reporting of adverse transfusion Reactions
•Draw blood sample ( plane & EDTA) immediately
from the contra lateral arm
•Disconnect the tranfusion set along with the
remaining blood bag
•Fill adverse transfusion event form
•send to blood bank for re assessment of
compatibility
84

85. Blood loss-SYMPTOMS & SIGNS
Dr Mona Shroff www.obgyntoday.info 85
Blood loss
(% B Vol)
Systolic BP
( mm of Hg)
Signs & Symptoms
10-15 Normal postural hypotension
15-30 slight fall PR, thirst,
weakness
30-40 60-80 pallor,oliguria,
confusion
40+ 40-60 anuria, air hunger,
coma, death

86. Complications of Massive transfusion
•Dilutional thrombocytopenia
•Coagulation factor depletion
•Lactic acidosis
• Hypothermia
86

87. Prevention of complications associated
with of massive transfusion
•1 unit of FFP for every 4 units of PRC
•1 unit of fresh blood for every 5 units of stored blood
•10% calcium gluconate 10 ml IV for every 5 units of PRC (citrated
blood)
87

88. Prevention of complications
of massive transfusion
Warming blood
Micro aggregate blood filters
88