2. 2
ContentsContents
Procurement and processing
Clinical use of red cells, platelets, plasma, and
cryoprecipitate
Adverse effects
Alternatives
Good transfusion practices
3. 3
Saudi Food and Drug Authority enforces
strict standards for
screening donors
for collection, processing and distribution of
blood and components
Saudi Ministry of Health
Blood Services are responsible for
donor recruitment
collection, processing and distribution of
blood components
referral centers
Hospitals
hospital blood banks
hospital transfusion services
- also responsible for supply of manufactured
products (e.g. albumin, clotting factor VIII)
BasicsBasics
4. 4
Types of donationsTypes of donations
1. Voluntary (including mobiles) -70% in RBB1. Voluntary (including mobiles) -70% in RBB
2. Replacement – 30% in RBB2. Replacement – 30% in RBB
3. Autologous and Directed Donations - rare3. Autologous and Directed Donations - rare
Autologous blood
(patient’s own blood) may
be collected in advance of
elective surgery by blood
center or at the treating
hospital
Directed donations from
parent to minor child,
from selected donors for
patients with rare blood
types or platelet refractor-
iness are available through
the blood center
5. 5
Donor RegistrationDonor Registration
Each donation is registered
by Identification, and a
Record of Donation,
consisting of two parts:
Questions about e.g.
general health, travel
Questions by a skilled
interviewer about “risk
behaviors” e.g. illicit drug
use
6. 6
Donor ScreeningDonor Screening
* Hb estimation
* Sickle cell testing
* ABO grouping
* Rh-D typing
Medical Examination
* General Health
* Pulse
* BP
* Temperature
* Skin
7. 7
Testing the Donation I.Testing the Donation I.
All donations are tested for some
infectious agents:
HIV by antigen/antibody, and NAT
HCV by antibody, and NAT
HBV by HBsAg/antibody to HBc
total and NAT
HTLV by antibody
Syphilis by antibody (RPR/TPHA)
Malaria by slide
8. 8
Testing the Donation II.Testing the Donation II.
Red cell type Antibodies present Recipient
Compatibility
Approximate
frequency
Group O (no ABO
antigens)
Anti-A, anti-B All ABO groups 42%
Group A Anti-B Groups A & AB 30%
Group B Anti-A Groups B & AB 20%
Group AB Neither present Group AB 08%
Rhesus group D
positive
Normally none Should be RhD
identical, RhD –ve
acceptable
92%
Rhesus group D
negative
Normally none Should be RhD
identical
08%
9. 9
Removal of White CellsRemoval of White Cells
(Leukoreduction(Leukoreduction))
Leukoreduction: Most of blood
donations have the white cells removed
(>99.99%)
Provide no benefit
Predispose to febrile reactions and
platelet refractoriness
Harbor organisms (e.g. CMV, HTLV)
Theoretical risk of abnormal prion
transmission is reduced
Theoretical risk of immuno-suppression is
reduced
10. 10
Making ComponentsMaking Components
Donation of 450mL blood in
63mL anticoagulant yields:
160mL red cells in total of
280mL, including added nutrient
About 250mL frozen plasma
5.5x1010
platelets in 70mL
Cryoprecipitate (fibrinogen, factor
VIII, von Willebrand factor) in 15mL
11. 11
Components – Shelf-life, Storage & CompatibilityComponents – Shelf-life, Storage & Compatibility
Component Shelf-life Storage Compatibility
requirements
Red blood cells 42 days (35 for
autologous)
1-6o
C ABO, RhD compatible,
identical if possible
Platelets (random
donor)
5 days 20-24o
C with
constant mixing
ABO RhD identical if
possible; blood group
barriers may be crossed
Platelets (single
donor apheresis)
5 days 20-24o
C with
constant mixing
Same as above.
Anti-D prophylaxis
required for some
recipients
Fresh Frozen
plasma
12 months Minus 18o
C or
lower
ABO compatible
preferred
Cryoprecipitate 12 months Minus 18o
C or
lower
ABO compatible
preferred
12. 12
Importance of Patient IdentificationImportance of Patient Identification
to Safe Transfusion Practiceto Safe Transfusion Practice
The root cause of most major blood
group incompatible reactions is failure
to identify the patient:
when taking the specimen for cross-match
when hanging the red cell bag.
Accurate and careful identity checks are
required:
At specimen procurement
At each stage of handling in the laboratory
At the place of transfusion before starting
the transfusion
13. Serious Hazards of Transfusion n=1148Serious Hazards of Transfusion n=1148
Major Morbidity in UK for 1996-2001Major Morbidity in UK for 1996-2001
Wrong blood
61%
Acute Hemolytic
13%
Delayed Hemolytic
12%
TRALI
6%
PT-Purpura
3%
Infectious
3%
GVH
1%
Other
1%
Other
5%
14. 14
National Haemovigilance Programme, SingaporeNational Haemovigilance Programme, Singapore
Aug 2004 - Dec 2007 (total reported cases 1,939)Aug 2004 - Dec 2007 (total reported cases 1,939)
15. 15
When to Order “Group & Screen”When to Order “Group & Screen”
and When to Consider Cross-matchand When to Consider Cross-match
1.Transfusion MIGHT occur during
admission
2. Surgery planned with <10% risk
of transfusion
1. Transfusion PLANNED
2. Surgery with at least a 10%
risk of transfusion
Group & Screen Group & Screen & Cross-match
Group
ABO Group, Rh Group
Screen
Cross-match
Antibody Screen
Anti-globulin cross-match, or
abbreviated cross-match
16. 16
Red Blood Cell TransfusionRed Blood Cell Transfusion
This section covers:
Contents of a unit of red cells
Patient testing
Selection of compatible units
Expected outcome of transfusion
Good transfusion practices
Guidelines for use of red cells
17. 17
Red Blood Cells for TransfusionRed Blood Cells for Transfusion
A unit of red cells contains 280mL, made up of
160mL of red cells
60mL of plasma
60mL of anticoagulant (citrate) and preservative
18. 18
Blood Grouping ProcedureBlood Grouping Procedure
Upper image: reactions
determining the ABO and
RhD type
Lower image: antibody
screening reactions on 3
patients.
Middle 2 tubes: unexpected
antibody to screening cell 1
19. 19
Selecting Compatible Red Cells I.Selecting Compatible Red Cells I.
Identical ABO and RhD type preferred
Red cells of non-identical ABO type may be used as
displayed above:
Group O cells may be given for all other ABO types
AB cells can only be given to AB patients
20. 20
Selecting Compatible Red Cells II.Selecting Compatible Red Cells II.
The RhD antigen is highly immunogenic
Transfusing RhD +ve blood to an RhD -ve
patient should be avoided wherever possible
RhD –ve females with child-bearing potential should never receive any
RhD +ve products unless there is no alternative
Such female RhD –ve patients should receive prophylactic treatment with
anti-D
Patients with an unexpected antibody should receive only red cells lacking
the corresponding blood group antigen
21. 21
Transfusion of Red CellsTransfusion of Red Cells
A unit of red cells is expected
to raise the hemoglobin 10 g/L
Transfuse a single unit over 2
hours and not more than 4
hours
Assess the outcome (clinical,
hemoglobin level) before
transfusing further
22. 22
The 10 FactsThe 10 Facts
1. Base decisions on national guidelines
2. Minimize blood loss and use conservation
measures
3. In acute blood loss, use effective resuscitation
while assessing transfusion needs
4. Hemoglobin level not the only consideration in
decision to transfuse
5. Transfusion only one element in treatment
6. Be aware of risks of transfusion
23. 23
The 10 Facts contd…The 10 Facts contd…
7. Prescribe only when the benefits outweigh the risks
8. Clearly record the reason for transfusion
9. Monitor the first 15 minutes of the transfusion for adverse
events
10. Obtain informed consent for transfusion of any blood
product
• Must be given voluntarily and clearly documented
• Patient must have the capacity to give consent
• Consent must be specific to the treatment proposed
• Patient must understand the nature, risks and benefits
24. 24
Transfusion in Acute Blood LossTransfusion in Acute Blood Loss
Maintain hemoglobin over 70 g/L during active bleeding
Anticipate need when hemoglobin drops below 80 g/L
Consider maintaining higher level (80-100 g/L) with:
Impaired pulmonary function
Increased oxygen consumption (e.g. fever)
Unstable coronary disease
Atherosclerosis
Uncontrolled bleeding
Patients with levels above 100 g/L are unlikely to
benefit
25. 25
Transfusion in the Critically IllTransfusion in the Critically Ill
No general benefit (& possible harm)
until hemoglobin falls to 70 g/L
Transfusion recommended below 70 g/L
Consider higher levels (100 g/L) in
patients with unstable angina or acute M
I
26. 26
Transfusion and the Peri-operative PatientTransfusion and the Peri-operative Patient
Pre-operatively, consider
alternatives in advance (at least 5
weeks) of surgery to allow
planning
Intra-operatively, meticulous
attention to surgical technique
Post-operatively, adhere to good
transfusion practice, minimize
blood taking for laboratory tests
27. 27
Transfusion and Chronic AnemiaTransfusion and Chronic Anemia
Consider alternatives and
adjuncts to transfusion
Ensure adequate stores of iron,
B12& folate
Erythropoietin
Treat underlying disease
Only transfuse when there is
no effective alternative
Maintain hemoglobin at a level
avoid symptoms of anemia
Monitor long-term transfusion
dependant patients for iron
overload
28. 28
PlateletsPlatelets
Platelets for transfusion
come in 3 forms:
Random donor, from single
donation, contains > 5.5x1010
platelets; given in pools of 5,
volume 300mL
Apheresis (single donor) platelets;
pack contains 30x1010
platelets,volume300m
HLA-matched apheresis platelets,
matched for specific recipients
immunized against HLA antigens
29. 29
Platelets – Storage & TransfusionPlatelets – Storage & Transfusion
Shelf life 5 days
Stored at 20-24o
C with constant mixing
Longer storage increases risk of septic reaction
Recommended infusion time 60 minutes
One pool of 5 units of random donor platelets, or
one apheresis platelet unit, should raise the platelet
count by >30x109
/L
Check post-transfusion platelet count within 1
hour of transfusion to determine response and
detect refractoriness
30. 30
Platelet transfusion responsePlatelet transfusion response
1. Calculation of Corrected Count Increment (CCI) in m² BSA/µL
CCI = Platelet count Increment X m² BSA/N
2. Post Platelet Recovery (PPR) in %age
PPR = Platelet count Increment X Blood Volume /N
N= Numbers of platelets transfused
NIH guidelines
* 2 consecutive CCI of < 5000 platelets x m² BSA/µL indicates refractoriness after 1 hr
* PPR of < 20 % also indicates refractoriness
31. 31
Platelets and Blood GroupPlatelets and Blood Group
ABO/RhD identical preferred
ABO/RhD non-identical are
acceptable
Rarely, incompatible plasma in
a platelet preparation may cause
a hemolytic reaction due to
high titre anti-A or anti-B
RhD –ve females of child-
bearing potential receiving RhD
+ve platelets require Rh-
immunoglobulin prophylaxis
32. 32
Clinical Use of Platelets I.Clinical Use of Platelets I.
Platelet count
(x109
/L)
Clinical setting Recommend
<10 Immune thrombocytopenia Transfuse platelets only with
serious bleeding
<10 Non-immune thrombocytopenia Transfuse 5 unit pool or 1 unit of
apheresis platelets
<10 Non-immune thrombocytopenia and HLA-
immunized
Transfuse 1 unit of HLA-
matched apheresis platelets
<20 Non-immune thrombocytopenia and fever
>38.5o
C or coagulopathy
Transfuse 5 unit pool or 1 unit of
apheresis platelets
<20 Procedures not associated with significant
blood loss
Transfuse 5 unit pool or 1 unit of
apheresis platelets
20-50 Procedures not associated with significant
blood loss
Have pool of 5 units or 1 unit of
apheresis platelets available,
transfuse only if there is serious
bleeding
33. 33
Clinical Use of Platelets II.Clinical Use of Platelets II.
Platelet count
(x109
/L)
Clinical Setting Recommended
<50 Epidural anesthesia and lumbar puncture Transfuse 5 unit pool or 1 unit of
apheresis platelets immediately
before procedure
<50 Procedures associated with blood loss or major
surgery (>500 mL expected blood loss)
Transfuse 5 unit pool or 1 unit of
apheresis platelets immediately
before procedure
<100 Pre-neurosurgery or head trauma Transfuse 5 unit pool or 1 unit of
apheresis platelets
Any Platelet dysfunction and marked bleeding (e.g.
post-cardiopulmonary bypass, anti-platelet
agents)
Transfuse 5 unit pool or 1 unit of
apheresis platelets
34. 34
Fresh Frozen PlasmaFresh Frozen Plasma
Fresh Frozen Plasma is a source of
clotting factors, with half lives in vivo
of between 6 hours & 3 days.
Available in 2 forms:
250 mL recovered from regular donations
500 mL from apheresis donation
30 minutes required for thawing
35. 35
Fresh Frozen PlasmaFresh Frozen Plasma
Dose and InfusionDose and Infusion
Dose is 10-15 mL/Kg, or 750-
1000 mL for average sized
adult
Infusion time 30-120 minutes
Should be ABO compatible
Single dose should restore
INR/PT/PTT to normal
Check INR/PT/PTT after
infusion to confirm outcome
36. 36
Reversal of Warfarin EffectReversal of Warfarin Effect
Warfarin effect can be reversed
with vitamin K, 10 mg iv, and
should be preferred to
transfusion if time permits
If not, 750-1000 mL should be
transfused
Expected result, INR/PT/PTT
1.5 x normal or less
Failure to get this result, re-
consider diagnosis
Warfarin reversal
effect
37. 37
Misuse of Frozen Plasma - AuditMisuse of Frozen Plasma - Audit
CMAJ 2002; 166: 1539.CMAJ 2002; 166: 1539.
Almost half of 358 patients received FFP
outside of guidelines
– Appropriate 55%
– Bleeding with INR<1.5 29%
– Not bleeding 9%
– INR not done 4%
– Other 3%
38. 38
CryoprecipitateCryoprecipitate
Cryoprecipitate contains
Fibrinogen – 250mg
Von Willebrand Factor
Clotting Factor VIII (anti-hemophilic factor) – 80IU
1 unit per 8-10 Kg body weight, or 8-12 units for an
average sized adult
Infusion time 10-30 minutes
Each dose should raise fibrinogen by 500 mg/dL
Check post-infusion fibrinogen level to confirm outcome
39. 39
DoseDose
Fibrinogen dose = Fibrinogen increment x Plasma Volume/100/250
1 bag contains 250 mg/dL of fibrinogen
Cryoppt. dose) = factor VIII level increment x Plasma Volume/100/80
1 bag contains 80 IU of factor VIII
40. 40
Clinical Use of CryoprecipitateClinical Use of Cryoprecipitate
Treatment of massive or microvascular bleeding with
Fibrinogen < 1.0 g/L
Status highly suggestive of hypofibrinogenemia without time for
laboratory confirmation
Massive rapid defibrination in the obstetrical patient
Hereditary Disorders of Hemostasis
For bleeding in von Willebrand’s syndrome patients ONLY if factor
concentrate is unavailable and DDAVP is ineffective
For the emergency management of factor VIII deficiency ONLY if
manufactured factor VIII is unavailable
