undergraduate teaching

1. Blood and blood products
Dr. Ankit Bhardwaj
Senior Resident
Dept. of Pharmacology

2. Introduction
• Only class of fluid with oxygen carrying capacity.
• Specialized type of connective tissue which acts as
transporter of vital substances to every part of body.
• Average blood volume in adult is 75ml/kg, and
constitute 8% of total body weight.
Introduction

3. Functions of blood
Distribution
functions
• Nutritive
• Respiratory
• Excretory
• Transport
Body fluid
regulation
function
• Maintenance
• Buffering
Protection
functions
• Preventing blood
loss
• Defensive
function

4. Blood deficiency signs and symptoms

5. Blood collection monitor and blood collection set

6. Blood and blood components storage units

7. Components of Blood
Protein 7%
Water 91%
Other solutes 2 %
Platelets 250-400
thousand
WBCs-5-9 thousand
RBCs – 4.2- 6.2 millions

8. Blood Products
Whole
Blood
Cellular
components
• Red cell concentrates
• Platelet concentrates
• Granulocyte concentrate
Plasma
derivates
• Albumin
• Immunoglobulin
• Coagulation Factors
Plasma
components
Fresh frozen plasma
Cryoprecipitate
Cryo poor plasma
Stored plasma

9. Whole Blood
Platelets rich
plasma
1 unit of Random
Donor Platelets
1 unit of fresh
Frozen plasma
Packed red blood
cells
High speed centrifugation
Slow centrifugation
Thawing precipitate the plasma
proteins
Cryoprecipitate
Blood components

10. Whole blood
• Whole blood = donor blood + anticoagulant
• 1 unit = 450 ml
• Anticoagulants (CPDS)
• Rich – coagulation factors
• Hct – 45%
• Stored at 2 – 6 ◦ C
• Shelf life – 35 days
Indications
 Acute blood loss with hypovolemia
 Severe iron deficiency or megaloblastic anemia
 Exchange transfusion
 severe anemia at birth
 severe hyperbilirubinemia
 Massive transfusion
 Major surgeries and Cardiovascular bypass

11. Red Cell concentrate
• Also called packed red cells
• Platelets and Plasma are removed
• 1 unit – 250 - 300ml
• HCT – 65 – 75%
• Shelf life – 35 days
• Stored at 2- 6◦ C
Indications
 Anemia ( symptomatic or life threatening)
 Thalassemia
 Sickle cell disease
 Severe parasitic infection ( malaria, babesiosis)
 Severe methemoglobinemia
 Severe hyperbilirubinemia of new-born

12. Fresh Frozen Plasma
• Removed – Fresh blood & Rapidly Frozen
• 1 Unit – 200 - 220ml
• Contains all coagulant factors
• Stored at - 40 to - 50˚c
• Shelf life – 1 years
Immediately administer within 30mins of thawing after
and complete within 20mins
Indication
 Single clotting factor deficiency
 • Multiple clotting factors deficiencies- DIC
 • Massive transfusions
 • Warfarin overdose
 • Hemorrhagic disease of neonates
 • TTP

13. Cryoprecipitate
• Fresh frozen plasma thawed at 4°C
• Rich in – F – VIII & Fibrinogen
• 1 unit = 15 - 20ml
• Stored at -40°C
• Shelf life – 1 year
• Immediately administer after issue and
complete within 30 mins
Indications
 Hemophilia A
 Von Willebrand’s disease
 FXIII or fibrinogen deficiency

14. Platelets concentrate
• Platelet rich plasma – Cent.
• Stored at – 22 to 24 ˚c
• Shelf life – 5 days
• 1 unit = 50 - 60ml
• Platelet count rise- 5000 – 10000/microliter
Indications
 Thrombocytopenia
 Drug induced Hge

15. Blood/ Blood
components
Volume unit Storage temperature Average shelf life Administration time Hb/hematocrit/platelet
count/rise
Whole blood 350 – 450 ml 2-6oC 35 days Administer within
30 minutes of issue
Or removal from freeze
complete
within 4 hours
Hb rise 1 g/dl
Hematocrit rise
3% ; the increase
may not be apparent
until when
patient blood
volume adjusts
to normal
Packed red blood cells
(PRBC)
250-300 ml 2-6oC 35 days Administer within
30 minutes of issue
Or removal from freeze
complete
within 4 hours
Hb rise 1 g/dl
Hematocrit rise
3% ; the increase
may not be apparent
until when
patient blood
volume adjusts
to normal
Random donor platelets
(RDP)
50-60 ml 22-24oC with agitation 5 days Immediately administer
after issue and complete
within 20 minutes
Platelet count
rise 5,000-10,000
/microliter
Single donor platelet (SDP) 250-300 ml 20-24°C with agitation 5 days Immediately administer
after issue and complete
within 20 minutes
Platelet count
rise 30,000-
40,000 /
microliter
Fresh frozen plasma (FFP) 200-220 ml -40oC 1 year Administer within
30 minutes of thawing
and complete
within 20mins.
20% increase
in coagulation
factors
Cryoprecipitate (CP) One Cryo unit/10 kg -40oC 1 year Immediately
administer after
issue and complete
within 30
minutes
Rise of FVIII
Indication for blood and blood components, storage requirement and shelf life of blood components

16. Compatible blood groups for blood components
• Red cell transfusion should always be ABO and RhD
compatible with recipient and cross-matched to confirm
compatibility before transfusion.
• Whole blood transfusion should always be group
specific.
• ABO identical platelets are the components of choice,
except in emergency.
• FFP must be ABO compatible.
• Cryoprecipitate can be given across ABO barrier.

17. Preparation
• Avoid obtaining either whole blood or packed RBC’s until
you’re ready to begin the transfusion.
• Explain the procedure to the patient or patient attendant.
• Make sure an informed consent has been signed
• Record baseline vital signs
• Check the expiration date on the blood bag, & observe for
abnormal color, RBC clumping, gas bubbles, & extraneous
material. Return outdated or abnormal blood to the blood bank.
• Compare the name & number on the patient’s wristband with
those on the blood bag label
• Check the blood bag identification number, ABO blood group,
and Rh compatibility.

18. Bed side checking
Identification of blood & blood products is performed at the patient’s bedside by two
licensed professionals, according to the facility’s policy.

19. • Avoid using an existing line if the needle or
catheter lumen is smaller than 20G.
• If you’re administering whole blood, gently invert
the bag several times to mix the cells.
• Adjust the flow clamp closest to the patient to
deliver the blood at the calculated drip rate.
• Remain with the patient and monitor vital signs
after every 15 mins in first hour.
• Avoid using an existing line if the needle or catheter
lumen is smaller than 20G.
• If you’re administering whole blood, gently invert the
bag several times to mix the cells.
• Adjust the flow clamp closest to the patient to deliver
the blood at the calculated drip rate.
• Remain with the patient and monitor vital signs after
every 15 mins for first hour.
Procedure

20. In your notes, record:
 Date and time of the transfusion
 Type and amount of Transfusion
 Patients vitals signs, every 15 mins in first hour,
then hourly minimum for 6 hours.
 Your check of all identification data.
 Transfusion reaction and nursing actions taken.
Documenting blood transfusion notes

21. • After completing the transfusion, you’ll need to put on gloves & remove & discard
the used transfusion equipment.
• Then remember to reconnect the original I.V. fluid, if necessary, or disconnect the
I.V. infusion.
• Return the empty blood bag to the blood bank.
Procedure

22. Don’ts Do’s
Ask for fresh whole blood Always give specific component therapy, if blood
components are available, following appropriate
guidelines
Delay transfusion after issue of blood component from
blood bank
PRBC - start within 30 minutes and complete within 4
hours
Platelets - start immediately and complete within 30
mins.
FFP – start within 30 mins and complete within 6hrs
Warm blood before transfusion Warm blood during rapid/ massive transfusion
FFP may be thawed in water bath with monitor
temperature (30-37◦C)
Store blood unit in domestic refrigerator in wards
Refrigerate platelet-they become nonviable.
Start transfusion immediately after issue. Return the
blood unit to blood bank within 30 mins if not required
Label the blood sample away from patient Always label the blood sample at bedside of the patients
using gum pasted labels.
Use IV set for transfusion Always use BT set with appropriate filter for transfusion,
which must be changed at prescribed interval
Leave patient unattended after starting transfusion Patient must be monitored to detect transfusion reaction
and mild reaction should not be ignore.
Do’s and Don’t for blood safety

23. Types of transfusion reaction
Immediate Delayed
• Immediate hemolytic transfusion reaction (IHTR) • Delayed hemolytic transfusion reaction (DHTR)
• Febrile non-hemolytic reactions (FNHTR) • Post-transfusion purpura (PTP)
• Transfusion related acute lung injury (TRALI) • Transfusion associated graft-versus-host disease
(TA-GVHD)
• Allergic reactions • TRIM
• Anaphylaxis and anaphylactoid reactions
Immune mediated reaction (ABO incompatibility)
Non-immune mediated reactions
Immediate Delayed
TACO • Iron overload
• Bacterial contamination
• Massive transfusion
 Metabolic
 Hypothermia
 Dilutional
 Pulmonary micro embolism
• Physical or Chemical RBC damage
• Air embolism

24. • At the time of transfusion (immediate <24 hours)
• A few (3 to 7) days after transfusion (delayed)
• Transfusion of incompatible RBCs
• ABO incompatible plasma containing products such as plasma and platelets;
• Chemically or physically induced
Hemolytic Transfusion Reaction (HTR)
The reaction period varies from 1 to 2 hours.
Signs and symptoms can occur within minutes after starting transfusion
Caused by-antibodies against the red cell antigens. The Involved cells are mainly
transfused cells rather than recipient cells.
Immune mediated IHTR can destroy RBCs by one of two mechanisms:
• intravascular or
• extravascular hemolysis
the initial event is the binding of patient antibody to the transfused incompatible
RBCs, which forms an antigen-antibody (Ag-Ab) complex on the RBC surface
Immediate hemolytic transfusion reaction

25. • Sudden clinical change.
• Fever ± chills.
• Anxiety ,chest or back pain ,flushing, dyspnea.
• Tachycardia, hypotension.
• If Patients under general anesthesia- things to look for
1. Severe hypotension.
2. Oozing.
3. Hemoglobinuria.
• Can be fatal: shock + intravascular coagulation .
Signs and symptoms

26. Interventions include:
• the transfusion
• Change tubing
• Maintain venous open with 0.9% normal saline
• Notifying health care provider and blood bank: send
transfusion set, blood samples (post transfusion sample in
2 ml EDTA vial and 5 ml Plain vial) along with complete
Adverse Transfusion reaction report Form.
• Send first void urine sample.
• Monitor closely, preparing to administer emergency
medications (e.g., antihistamines, vasopressors,
corticosteroids)
• Returning all blood tubing and bags to blood bank

27. • The American Association Of Blood Banks (AABB) technical manual defines
FNHTR as a 1°c temperature rise associated with transfusion and having no
medical explanation other than blood component transfusion.
• In 0.5%-3% cases.
• Usually in multi-transfused patients.
• Reactions run the course for few hours.
• Mild degree (fever, chills) , rarely severe.
Causes
• Alloimmunization to platelet & leukocyte antigens.
• Bacterial contamination.
• Accumulated Cytokines in the stored blood.
Febrile nonhemolytic transfusion reactions (FNHTR)

28. • Estimated incidence of 1-3%.
• Actual incidence may be higher as often they are not reported.
• Minor reaction to anaphylactic shock.
• Minor reactions are dose (volume of plasma) related.
• Common pathogen- whole blood & plasma.
• Less commonly- PRBC.
• Rarely- washed RBCs or albumin.
• Most patients do not have repeated occurrence of the reaction.
• Patients with h/o atopy- higher risk of additional reaction.
Allergic reaction

29. Signs and symptoms
• Urticaria (hives).
• Other skin lesions.
• Bronchospasm.
• Angioedema.
• Anaphylactic shock
 plummeted BP.
 respiratory distress.
 other features of shock.
• If severe anaphylactoid /anaphylactic reaction- consider anti-IgA antibodies in
donor plasma.
• Incidence of genetically determined IgA deficiency -1 in 400 to 1 in 500.
• 20-25% of these patients develop anti-IgA antibodies even without prior
transfusion.
• If titer ≥ 1 in 256 –high likelihood of major post-transfusion reaction even after
administration of few ml of plasma.
Anaphylactic Reaction

30. Prevention
• Premedication with antihistamine in patients with repeated allergic reactions.
• Reduction of plasma content if maximum premedication fails.
• Reduction of plasma content-
centrifugation of the product.
washing the RBCs.
• Patients with high anti-IgA titer-
transfusion with washed RBCs.
IgA deficient blood product.
Management
• Minor urticarial reactions – only reactions not requiring discontinuation of
transfusion.
• Discontinue otherwise or in severe reaction.
• Premedication with antihistamine.
• In severe reaction/anaphylaxis,
-airway
-breathing
-circulation (adrenaline ).

31. • Life threatening thrombocytopenia.
• Developed 5-10 days post-transfusion.
• Development of alloantibodies against platelet- specific antigens.
• Anti –HPA-1a is the usual antigen; others can also be implicated.
• Most patients sensitized by prior pregnancy or previous transfusion.
Passive post-transfusion purpura
 Passive administration of platelet –specific antibody via plasma containing
products.
 Anti-HPA-1a & anti-HPA-5a.
Important to identify these donors.
Management
 High dose IVIG / Corticosteroids
Post-transfusion purpura

32. • Most cellular blood products contain viable T- lymphocytes.
• Proliferation of these lymphocytes in immunocompetent /
immuno-incompetent hosts causes TA-GVH
Agents
 Leukocyte /platelet concentrate /fresh blood.
Manifestations
• Usually within 1 to 2 weeks post transfusion.
• MC symptom –fever.
• Typical erythematous , maculopapular skin rash follows
beginning centrally and spreading peripherally to the hands
and feet (TEN in severe cases).
• Abnormalities of hepatic function
• Nausea
• Bloody diarrhea ;profuse diarrhea (up to 8 L/d).
• Leukopenia followed by pancytopenia due to marrow failure
(most often 2 to 3 weeks after the onset of symptoms).
Graft versus Host disease (GVHD)

33. • Milder than immediate counterpart.
• Mostly extravascular.
• From 2-10 days after transfusion.
• Red cell antibody not detected in the pre-transfusion blood sample.
• Transient positivity of direct antiglobulin test.
• Test becomes negative as the incompatible red cells are removed from
circulation.
Delayed hemolytic transfusion reaction
Management:-
• Mostly, no therapy required.
• Hydration in a few-who experience severe reaction.
• Crossmatch-compatible blood negative for the offending antigen, if clinically
indicated.
• Take care about the future transfusion
• Physician & patient both should be informed about the incidence.
• Blood bank should keep the record.

34. • Number one cause of transfusion associated fatality (FDA).
• Incidence- 1 in 5000 to 1 in 13000.
• a syndrome of noncardiogenic pulmonary edema resembling ARDS.
Criteria of TRALI
• Acute lung injury
• Acute onset
• Hypoxemia
 SPO2 < 90% on room air or other clinical evidence of hypoxemia
 PaO2/FiO2 ratio < 300 mmHg
 Bilateral infiltrates on frontal CXR
 No evidence of left atrial hypertension (e.g. circulatory overload)
 No preexisting ALI before transfusion
 During or within 6 hours of transfusion
 No temporal relationship to an alternative risk factor for ALI
Transfusion related acute lung injury (TRALI)

35. • Stop the transfusion!
• Supportive measures for pulmonary edema & hypoxia.
• Ventilatory support if required.
• If fluid overload present- diuretics.
• Very high dose steroid- blocks granulocyte aggregation & consequent vascular
damage.
• Examination of donor plasma for granulocyte- specific & anti- HLA antibodies.
• Current AABB recommendation-
 Minimization of high- plasma- content component (FFP & pheresis platelets)
from donors at risk for alloimmunization (women with h/o pregnancy).
Management of TRALI

36. Complications
Disease transmission
• HIV and Hepatitis C are most commonly
transmitted disease
• Other transmitted diseases may include hepatitis
B, Epstein-Barr virus, cytomegalovirus, and
malaria
Hypocalcemia
Monitor for hyperactive reflexes, paresthesia,
cramps, positive Trousseau’s and Chvostek’s
signs.
 Slow transfusion rate, notify health care
provider if signs occur
Trousseau’s sign
Chvostek’s signs
• Trousseau's sign is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes
• Chvostek's sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve

37. Hyperkalemia
• The older the blood, the greater the risk for hyperkalemia,
because hemolysis causes potassium release.
• Monitor for muscle weakness, paresthesia's, abdominal
cramps, diarrhea, dysrhythmias
• Slow transfusion rate, notify health care provider if signs
occurs
Transfusion hemosiderosis
In patients chronically receiving transfusion therapy e.g –thalassemia.
Each unit of red cell -0.25 g of iron.
After a large no. of transfusion iron deposition occurs significantly.
Manifestations
• growth retardation.
• failure of sexual maturation.
• myocardial dysfunction
• hepatic dysfunction
• hyperpigmentation
• diabetes (bronze diabetes)
Management
Prophylaxis by iron chelator (deferoxamine).