1. BLOOD TRANSFUSION
Dr PRIYAVART MEHARWAL
RESIDENT-2Yr
(PATHOLOGY DEP.)
2. History of Transfusions
• Blood transfused in humans since mid-
1600’s
• 1828 – First successful transfusion
• 1900 – Landsteiner described ABO
groups
• 1916 – First use of blood storage
• 1939 – Levine described the Rh factor
7. Cross matching
1. Matching blood components between a Pt & a D
is a direct compatibility test.
2. The red cells & Plasma are cross matched thru
Major and Minor cross match, defined as to an
amount of Antibody react with Antigen
A. Major‘:the patient's serum & the donor's RBCs.
–large amount of Antibody has greater impact
B. Minor’: the patient's RBCs & the donor's serum.
–Small amount of Antibody has little impact
10. WHAT IS ANTIGENS ?
An antigens is a substance that causing
the formation of antibodies
WHAT IS ANTIBODYS ?
Antibodies is a protein substance
develop in the body in response to the
presence of an antigen that has
entered the body
12. Transfusion Overview
• Integral part of medical treatment
• Most often used in Hematology/Oncology, but other
specialties as well (surgery,gyn, ICU, etc)
• Objectives
– Blood components
– Indications for transfusion
– Safe delivery
– Complications
13. PURPOSE OFBLOOD
TRANSFUSION
THERAPY
* REPLACEMENT
* THERAPEUTIC
1.To restore intravascular volume with
whole blood or albumin.
2. To restore the oxygen capacity of
blood by replacing red blood cells.
3. To replace clotting factor and
correction of anemia
14. Blood Transfusion
Type of Transfusion：
Whole Blood；
Blood Component；
RBC PLT FFP Leukocyte concentrate
Plasma Substitutes；
Use of whole blood is considered to be a waste of
resources
15. DEFINITIONS
BLOOD PRODUCT = Any therapeutic substance prepared from
human blood
WHOLE BLOOD = Unseparated blood collected into an approved
container containing an anticoagulant preservative solution
BLOOD COMPONENT = 1. A constituent of blood , separated
from whole blood such as
• Red cell concentrate
• Plasma
• Platelet concentrates
2. Plasma or platelets collected by apheresis
3. Cryoprecipitate prepared from fresh frozen plasma
16. Differential Centrifugation
First Centrifugation
Closed System
Whole Blood Satellite Bag Satellite Bag
Main Bag 1 2
First
Platelet-rich
RBC’s Plasma
17. Differential Centrifugation
Second Centrifugation
RBC’s Platelet-rich
Plasma
Second
Platelet Plasma
RBC’s Concentrate
18. Whole Blood
• Storage
– 4 for up to 35 days
• Indications
– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations
– Use filter as platelets and coagulation factors will not be
active after 3-5 days
– Donor and recipient must be ABO identical
19. Blood Components
THE PRBC
Storage
-2–6OC
Unit of issue
- 1 donation ( unit or pack )
Administration
- ABO & Rh compatible
- Never add medication to a unit
- Complete transfusion within 4 hrs of
commencement
M 1
e
m
20. Indications
- Acute blood loss with > 20% loss
of blood volume
Trauma
Surgery - Trigger – 10gm% - 8gm%
Rate of development of anemia,
General condition and type of
surgery
Radiotherapy
21. Dosage & Administration
Dosage - 1 unit/10 kg body wt
Adult dose is 4-8 units
Administration - Preferably ABO
& Rh group specific
22. Platelets
• The platelets are separated from the plasma by
centrifugation.
• Platelets are supplied either as single donor units or
as a combination of multiple donors.
• One unit of platelets will increase the platelet count
of a 70 kg adult by 5 to 10,000/mm³.
• Platelet viability is optimal at 22° C but storage is
limited to 4-5 days.
• Platelets have both the ABO and HLA antigens. ABO
compatibility is ideal but not required.
(incompatibility will shorten the life span of the
platelet)
23. Platelets
• Storage
– Up to 5 days at 20-24
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations
– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by 50,000
– Donor and Recipient must be ABO identical
24. Platelets
• Thrombocytopenia
(< 50,000)
• Platelet dysfunction
• Each unit increase 5,000
PLTs after 1 H
25. Guidelines for Platelet Tx.
Mild - 50,000-1,00,000/µl
Tx - usually not required
Moderate - 20,000-50,000/µl
Tx-if symptomatic or has to
undergo surgery/trauma
Severe - < 20,000/µl
Risk of bleeding - high
Prophylactic Tx
26. Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml)
• Storage
– FFP--12 months at –18 degrees or colder
• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion
• Considerations
– Plasma should be recipient RBC ABO compatible
– In children, should also be Rh compatible
– Account for time to thaw
– Usual dose is 20 cc/kg to raise coagulation factors approx 20%
27. Fresh Frozen Plasma (FFP)
• Coagulation factor deficiencies
• 1 ml increases 1% clotting
factors
• Being used as soon as possible
• Albumin, hetastarch,
crystalliods are equally
effective volume expander but
safer than FFP
• After use of 5 U of RBCs,
matching 2 U of FFP
28. Dosage & Administration for
FFP
Dosage - 10-15 ml/Kg(Approx
2-3 bags for an adult)
Administration - Thawed at
+37o C before transfusion
ABO compatible
Group AB plasma can be used
for all patient
29. Plasma Substitutes
Dextran
• Most widely used
• Low/Middle M.W. (40,000-70,000)
• Massive transfusion could impair coagulation
• Occasional ALLERGIC reaction
Hydroxyethyl Starch Formulation (HES)
• More stable
• Containing essential electrolytes
• No allergic reaction
--Volume Expander
30. Granulocyte Transfusions
• Prepared at the time for immediate transfusion (no
storage available)
• Indications – severe neutropenia assoc with infection
that has failed antibiotic therapy, and recovery of BM
is expected
• Donor is given G-CSF and steroids or Hetastarch
• Complications
– Severe allergic reactions
– Can irradiate granulocytes for GVHD prevention
31. Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is thawed at 4
• Storage
– After collection, refrozen and stored up to 1 year at -18
• Indication
– Fibrinogen deficiency or dysfibrinogenemia
– vonWillebrands Disease
– Factor VIII or XIII deficiency
– DIC (not used alone)(Disseminated intravascular coagulation)
• Considerations
– ABO compatible preferred (but not limiting)
– Usual dose is 1 unit/5-10 kg of recipient body weight
32. Leukocyte Reduction Filters
• Used for prevention of transfusion reactions
• Filter used with RBC’s, Platelets, FFP, Cryoprecipitate
• Other plasma proteins (albumin, colloid expanders,
factors, etc.) do not need filters—NEVER use filters
with stem cell/bone marrow infusions
• May reduce RBC’s by 5-10%
• Does not prevent Graft Verses Host Disease (GVHD)
33. RBC Transfusions
Preparations
• Type
– Typing of RBC’s for ABO and Rh are determined for both
donor and recipient
• Screen
– Screen RBC’s for atypical antibodies
– Approx 1-2% of patients have antibodies
• Crossmatch
– Donor cells and recipient serum are mixed and evaluated
for agglutination
34. RBC Transfusions
Administration
• Dose
– Usual dose of 10 cc/kg infused over 2-4 hours
– Maximum dose 15-20 cc/kg can be given to hemodynamically stable
patient
• Procedure
– May need Premedication (Tylenol )
– Filter use—routinely leukodepleted
– Monitoring—VS q 15 minutes, clinical status
– Do NOT mix with medications
• Complications
– Rapid infusion may result in Pulmonary edema
– Transfusion Reaction
35. Platelet Transfusions
Preparations
• ABO antigens are present on platelets
– ABO compatible platelets are ideal
– This is not limiting if Platelets indicated and type specific
not available
• Rh antigens are not present on platelets
– Note: a few RBC’s in Platelet unit may sensitize the Rh-
patient
36. Platelet Transfusions
Administration
• Dose
– May be given as single units or as apheresis units
– Usual dose is approx 4 units/m2—in children using 1-2
apheresis units is ideal
– 1 apheresis unit contains 6-8 Plt units (packs) from a single
donor
• Procedure
– Should be administered over 20-40 minutes
– Filter use
– Premedicate if hx of Transfusion Reaction
• Complications—Transfusion Reaction
37. Choice of blood group for transfusion
Patient blood first choice second choice
1. O + O+ 0-
2. O- O- -
3. A+ A+ A-,O+,O-
4. A- A- O-
5. B+ B+ B-,O-,O+
6. B- B- O-
7. AB+ AB+ AB+,A+,A-,B+,B-,O-,O+
8. AB- AB- A-,B-,O-,
38. • Although blood transfusions can be
life-saving, they are not without risks.
The most serious risks are
transfusion reactions and infections.
42. Frequency of Transfusion Reactions
Adverse Effect Frequency Comments
Acute Hemolytic Rxn 1 in 25,000 Red cells only
Anaphylactic hypotensive 1 in 150,000 Including IgA
Febrile Nonhemolytic 1 in 200 Common
Allergic 1 in 1,000 Common
Delayed Hemolytic 1 in 2,500 Red cells only
RBC alloimmunization 1 in 100 Red cells only
WBC/Plt 1 in 10 WBC and Plt only
alloimmunization
43. Acute Hemolytic Transfusion Reactions
(AHTR)
• Occurs when incompatible RBC’s are transfused into a
recipient who has pre-formed antibodies (usually ABO or Rh)
• Antibodies activate the complement system, causing
intravascular hemolysis
• Symptoms occur within minutes of starting the transfusion
• This hemolytic reaction can occur with as little as 1-2 cc of
RBC’s
• Labeling error is most common problem
• Can be fatal
44. Symptoms of AHTR
• High fever/chills
• Hypotension
• Back/abdominal pain
• Oliguria
• Dyspnea
• Dark urine
• Pallor
45. What to do?
If an AHTR occurs
• STOP TRANSFUSION
• ABC’s
• Maintain IV access and run IVF (NS or LR)
• Monitor and maintain BP/pulse
• Give diuretic
• Obtain blood and urine for transfusion reaction
workup
• Send remaining blood back to Blood Bank
46. Blood Bank Work-up of AHTR
• Check paperwork to assure no errors
• Check plasma for hemoglobin
• Repeat crossmatch
• Repeat Blood group typing
• Blood culture
47. Labs found with AHTR
• Hemoglobinemia
• Hemoglobinuria
• Hyperbilirubinemia
• Abnormal DIC panel
48. Febrile Nonhemolytic Transfusion
Reactions (FNHTR)
• Definition--Rise in patient temperature >1 C
(associated with transfusion without other fever
precipitating factors)
• Occurs with approx 1% of PRBC transfusions and
approx 20% of Plt transfusions
• FNHTR caused by alloantibodies directed against HLA
antigens
• Need to evaluate for AHTR and infection
49. Allergic Nonhemolytic Transfusion
Reactions
• Etiology
– May be due to plasma proteins or blood
preservative/anticoagulant
– Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
• Presents with urticaria and wheezing
• Treatment
– Mild reactions—Can be continued after Benadryl
– Severe reactions—Must STOP transfusion and may require
steroids or epinephrine
• Prevention—Premedication (Antihistamines)
50. TRALI
Transfusion Related Acute Lung Injury
• Clinical syndrome similar to ARDS
• Occurs 1-6 hours after receiving plasma-
containing blood products
• Caused by WBC antibodies present in donor
blood that result in pulmonary leukostasis
• Treatment is supportive
• High mortality
51. Monitoring in AHTR
• Monitor patient clinical status and vital signs
• Monitor renal status (BUN, creatinine)
• Monitor coagulation status (DIC panel–
PT/PTT, fibrinogen, D-dimer/FDP, Plt,
Antithrombin-III)
• Monitor for signs of hemolysis (LDH, bili,
haptoglobin)
52. Bacterial Contamination
• More common and more severe with platelet
transfusion (platelets are stored at room
temperature)
• Organisms
– Platelets—Gram (+) organisms, ie Staph/Strep
– RBC’s—Yersinia, enterobacter
• Risk increases as blood products age (use
fresh products for immunocompromised)
54. Transfusion Associated Infections
• Hepatitis C
• Hepatitis B
• HIV
• CMV
– CMV can be diminished by leukoreduction, which
is indicated for immunocompromised patients
55. ABO System & Pregnancy
hemolytic diseases of the newborn may be due to
ABO incompatibility
ABO incompatibility is a common and generally mild
type of haemolytic disease in babies. The term
haemolytic disease means that red blood cells are
broken down more quickly than usual which can
cause jaundice, anaemia and in very severe cases can
cause death. During pregnancy, this breakdown of red
blood cells in the baby may occur if the mother and
baby’s blood types are incompatible and if these
different blood types come into direct contact with
each other and antibodies are formed.
56. Significant problems with ABO incompatibility
occur mostly with babies whose mothers
have O blood type and where the baby is
either A or B blood type. Premature babies
are much more likely to experience severe
problems from ABO incompatibility, while
healthy full term babies are generally only
mildly affected. Unlike haemolytic disease
that can result in subsequent babies when a
mother has a negative blood group, ABO
incompatibility can occur in first-born babies
and does not become more severe in further
pregnancies
57. After birth there are two options for testing
for ABO incompatibility:
The cord blood of all babies whose mothers
have an O blood group and the father either
type A or B blood is tested The theory behind
this approach is that if the baby is type A or B
and they test positive in direct antiglobulin
tests (DAT), the baby can then be followed
closely for jaundice.
The alternate approach is to screen any baby
who becomes significantly jaundiced
(particularly within the first 24 hours
58. Rh FACTOR
• This can induce varying degrees of anemia in the foetus, with
hiperbilirubinemia, organ malfunction, etc. Bilirubin deposition in the
cerebral basal ganglia (kernicterus)can lead to severe mental damage.
Severe cases of this disease were mortal.
• Prevention started in the 60's and nowadays Rh negative pregnant women
receive immunoglobulin doses at several moments during pregnancy and
after childbirth if the baby is Rh positive. Besides, women in fertile age are
never transfused Rh positive blood. Thus, HDN due to Rh antibodies has
practically disappeared in developed countries.
59.
60. Rhesus Isoimmunization
Rhesus Iso immunization is an immunologic disease
that occurs in pregnancy resulting in a serious
complication affecting the fetus / or the neonate
ranging from
… mild neonatal jaundice
… to intra uterine loss or neonatal death
61. Rhesus Isoimmunization
This immunologic disease occur when
a Rh – negative patient carrying a Rh – positive fetus
….. had a feto – maternal blood transfusion
….. the mother immunological system is stimulated
to produce antibodies to the Rh antigen on the
fetal blood cell
….. This antibodies cross the placenta and destroy
fetal red blood cells leads to fetal anemia
…. Usually the 1st fetus will not be affected if this is
the 1st time that the mother has been exposed to
the rhesus positive antigen
62. Management
of rhesus negative pregnant women
Management of non sensitized Pregnancy
Management of sensitized Pregnancy
63. Prophylactic Management of non sensitized Pregnancy
During antenatal period
Prophylactic (500 IU / 100 mcg ) Anti D
are recommended to be given to all
negative non sensitized mothers married to
Rh positive husband at
28weeks and 34 weeks to protect and
overcome any asymptomatic or un noticed
antenatal feto maternal blood transfusion
64. Management of Sensitized Pregnancy
Intra uterine therapy
Intra peritoneal blood transfusion
Through the umbilical vein “ Cordocentesis
80 % of packed cell “ o “ rhesus
negative Blood Cross matched against
maternal blood group
Free of infection
Fresh
