This document provides information about blood transfusion and component therapy. It discusses the need for transfusion when there is inadequate oxygen carrying capacity or coagulation proteins. Whole blood can be separated into components like red blood cells, platelets, plasma, and cryoprecipitate to provide targeted therapy. The storage and indications of various blood components like packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets are described. The document also covers transfusion triggers, guidelines, blood ordering schedules, and blood sparing strategies like autologous donation and acute normovolemic hemodilution.

1. BLOOD TRANSFUSION
AND
COMPONENT THERAPY
Dr.Indubala Maurya
Assistant professor
Department of Anaesthesia & critical care
MGMCRI

2. Lecture
 Part 1 ( blood products and its uses )
 Part 2 ( Complication of blood transfusion )

4. What Is The Need For Transfusion
 INADEQUATE O2 CARRYING CAPACITY
- Anemia
- Blood loss
 INADEQUATE COAGULATION PROTEINS
-To provide adequate homeostasis

5. General Rules For Transfusion
 Should not be the first choice
 Should have a policy regarding typing, cross
matching for those surgeries where it is not
required
 Autologous transfusion should be promoted

6. Whole Blood Transfusion
or
Component Therapy
 Can give individual component for specific illness
 Patient does not require all the components
 This policy can benefit more than one individual

7. One Unit Of Whole Blood
 One unit of RBC’S
 One unit of Platelets
 One unit of Cryoprecipitate
 One unit of Plasma (minus above 2 )
1 unit of whole blood = 450 ml blood
63 ml anticoagulant preservative

8. Blood Components
Cellular components Plasma components Plasma derivatives
Red cell concentrate Fresh frozen plasma Albumin 5% and 25%
Leucocytes-reduced red
cells
Single donor plasma Plasma protein
fractions
Platelet concentrate Cryoprecipitate Factor VIII concentrate
Leucocytes-reduced
platelet concentrate
Cryo-poor plasma Other coagulation
factors
Platelet apheresis Immunoglobulins
Granulocyte apheresis

9. COMPATIBILITY TESTING

10. Changes In RBC’s During
Storage
 Decrease in ATP (can be improved with glucose, phosphate &
adenine)
 Decrease in 2,3 DPG
 Hyperkalaemia , Acidosis in storage
 RBC lysis & decrease in Hb (6 weeks storage- RBC recovery 85%)
 Membrane damage making it difficult to penetrate microcirculation
( can be improved with Mannitol / Citrate)
 Decrease in viability ( shelf life of stored RBC’s is 35 – 42 days)

11. Anticoagulants
AIM – To increase the RBC life, safety & overall effectiveness
1. CPDA (35 Days)
2. SAGM- Saline ,Adenine , Glucose, Mannitol
3. AS-1, AS-3 ,AS -5 ( Additive solution) (42 Days)
4. Extended storage preservative solution containing
- Dextrose
- NaCl
- Citric acid
- Sodium citrate
- Adenine and Mannitol

12. Status Of Heparin
Though an anticoagulant ,but maintains viability only
upto 24 – 48 hrs
MAIN USE
- ECMO
- Exchange transfusion

13. LIGHT SPIN at 2000 rpm for 3 minutes at 22º
RESULT - Packed RBC
- PRP
WHY LIGHT SPIN?
 To avoid damage to Platelets
 Process required to be done within 6 hrs of whole blood
collection
 Packed RBC’s are suspended in a hematocrit of 70% (CPDA-1)
or 60 % ( AS -1 or AS- 3,5)

14. HEAVY SPIN at 5000 rpm ,5 minutes & 4ºC
RESULT- PPP
Heavy spin → Damage to platelets
Volume → 200 – 400 ml per whole blood
transfusion bag

15. Platelet Poor Plasma (PPP)
FRESH PLASMA
Prepared & infused within 6 hrs of preparation
FRESH FROZEN PLASMA
Fresh plasma stored at -20ºC in a freezer
Is stable for 1 year
Both forms of PPP have all the Coagulation factors &
proteins

16. High spin at 4 ºC to PPP
RESULT
- Cryoprecipitate
- Cryosupernant
Cryoprecipitate
 Concentrated source of Von- Willebrand factor, fibrinogen, Factor VIII
and fibronectin
 Stable for 1 year
Cryosupernant
 Remaining plasma after removal of cryoprecipitate

17. Fresh Whole Blood
Packed Red Cells
Light spin, 22o
C
Platelet Rich Plasma
Platelet Concentrate Fresh Plasma
Store at 22o
C Freeze(FFP)
Heavy spin, 4o
C

18. Thaw at 4o
C & heavy spin
Fresh Frozen Plasma
Cryoprecipitate
-Refrozen within 1 hr
-Store at < - 18
o
C
Cryoremoved Plasma
Freeze -80o
C immediately
Stored at < -18o
C

19. VOLUME
WHOLE BLOOD → PPP → CRYOPRECIPITATE
450ml 250ml 10-20 ml

20. Packed RBC’s
 Most frequently required and used
 Benefit – Will increase amount of O2 delivery to tissues
 1 unit PRBCs = 200 ml RBCs
100 ml additive solution
30 ml plasma
 Storage - 1ºC to 6 ºC
 Normally, 20 days viability in CPDA solution
 Post transfusion viability - 75 %

21. Indications
Broadly
 Anaemia
 Haemorrhage
Other Indications
 Critically ill patients of sepsis and trauma
 Acutely bleeding patients
- Rapid loss of > 15 % if preexisting Hb is < 10 gm / dl

22. Indications contd….
 Perioperative period
- < 8 gm / dl without significant Heart, Lung, Vascular, Renal
or Neural disease
- < 10 gm / dl with significant underlying diseases
 Patients of chronic Anemia
- Hb < 8 gm / dl with evidence of CHF, Angina or Hypovolemia
 Patients of marrow failure
- Hb < 10 gm / dl with Leukemia, Lymphoma , Aplastic anemia

23. Clinical Indications Of PRBCs
Transfusion
 SBP < 90 mm Hg
 Fall in SBP > 40 mm Hg within 4 hrs
 DBP < 40 mm Hg within 4 hrs
 Fall in DBP > 40 mm Hg within 4 hrs
 Heart rate > 100 bpm
 SpO2 < 90 mm Hg & PaO2 < 70 mm Hg

24. Leucocyte Reduced Blood
Components
WHY REQUIRED?
 Average unit of RBC’S contain 1 – 2 million WBC’s
 Average unit of platelets contain 50 million WBC’s
 Febrile and inflammatory reactions largely due to WBC’s
METHODS FOR REDUCTION
 Washing of RBC’s( Average life 24 hrs )
 Leucocytes reduction filters

25. Fresh Frozen Plasma (FFP)
 Primary source of coagulation factors
 Most common blood component to be used irrationally in today’s
practice
 1 unit of FFP = 200 – 250 ml plasma
 Expiry date 365 days
 Use – Thaw at 37 ºC for about 20 – 30 mins
 Once thawed , can be again stored for upto 24 hrs at 1- 6 ºC
SHOULD BE ABO COMPATIBLE OR IDENTICAL
CROSS MATCHING NOT REQUIRED

26. Indications
 Congenital coagulation factor deficiencies except VII ,VIII, IX
or Von Willebrand disease
 Acquired coagulation problems like liver disease, Vit. K
deficiency
 In massive blood transfusion to provide clotting factors
 Treatment of TTP
 Dose = 10 – 20 ml / kg
 1 unit of FFP = ↑ in factor levels by 3 -5 %

27. Cryoprecipitate
 1 bag of cryoprecipitate = 250 mg of fibrinogen
15 – 20 ml plasma
Von Willebrand factor (IX)
80 – 130 units of factor VIII
Fibronectin
Factor XIII 20 -30 %
 Expiry date= 365 days
 Once thawed , use in 4 hrs

28. Indications
 Congenital / Acquired Hypofibrinogenemia
 Congenital / Acquired Factor VIII deficiency
 Secondary choice in Uraemia

29. Platelets
CERTAIN FACTS
 Aphretic platelets collected from a single donor contains platelets
equivalent to 6 - 8 whole blood derived platelet concentrates
 Storage – 20 – 24 ºC ( Never refrigerate)
 Expiry – 5 - 7 days
 Use Platelet filters and not routine blood filters

30. Indications
 Blood platelet count < 50,000 /μl and evidence of significant active
bleeding
 Thrombocytopenia
 DIC
 Dengue
 Platelet count <10,000 /μlt without evidence of bleeding
 Bone marrow failure
 Functional platelet defect & bleeding
 Dose – 1 unit = ↑ 5000 – 10000 platelets in patient
 5 -6 unit = 1 aphretic unit
NO CROSS MATCHING REQUIRED

31. Transfusion Triggers
 The RBC , transfusion triggers is a term used to
describe, the set of circumstances under which
transfusion is reasonable and for which no further
justification is needed.
WHY the word TRIGGER ?

32. Transfusion Triggers contd…
Two type of Physiological Triggers
1) Invasive Triggers
1) Non invasive Triggers

33. Invasive Triggers
1. Mixed venous O2 (PVO2)
The rate of a fall is more important
2. Mixed venous O2 saturation ( SVO2)
Declines rapidly when haematocrit falls below 20 %
3. Oxygen uptake VO2
In sepsis and low perfusion not a true indicator as DO2 is
normal but due to low pressure VO2 is reduced.
Will transfusion benefit here?
4. Oxygen extraction ratio O2 ER
If it is > 50% , decompensation is imminent . Usually
happens at H’crit of 10%

34. Non invasive Triggers
DO remember
1. Minimum Hb reqd to have adequate DO2 for
isolated tissue is 3-5 gm/dl.
2. In healthy people, acute normovoluemic
hemodilution can be safely tolerated upto 5 gm
/dl.
3. Transfusion is reqd usually at Hb < 7 gm/dl.
4. Transfusion is unjustified at Hb >10 gm /dl.
5. Duration of Anemia.

35. ASA Guidelines for Blood
Component Therapy
RBC’s-Rarely for Hb>10 g/dl Usually for Hb<6g/dl Decision
based on risk for complications related to inadequate
oxygenation
Platelets-Rarely for PLT>100,000 Usually for PLT<50,000 For
PLT between 50,000 and 100,000 decision based on assessment
of risk
FFP-Microvascular bleeding present and PT or PTT is 1.5 times
normal .Condemns use for volume replacement
Cryoprecipitate- Consider for fibrinogen levels < 80 mg/dL
orwhen levels can not be rapidly obtained

36. Maximum Surgical Blood Ordering
Schedule (MSBOS)
List of procedures performed in a hospital together with
recommended quantity of RBC units to cross match ,
based upon the utilization data specific to that hospital
CROSS MATCH : TRANSFUSION ( C:T) ratio
 Should not exceed 2 :1
GROUP AND SAVE
 Procedure where transfusion is not reqd

37. Blood Sparing Strategies
Transfusion is either
Autologous
or
Homologous ( Allogenic )

38. Sparing Strategies in Preoperative
Period
 Diagnosing and effective treatment of preexisting
ailments like Iron deficiency anemia, bleeding disorders.
 Review of Anticoagulant therapy
 Adoption of MSBOS
 Utilizing Cell salvage.

39. Sparing Strategies in
Intraoperative Period
 Careful positing to reduce venous congestion
 To maintain Normothermia
 If possible controlled Hypotension
 Appropriate use of Diathermy , laser
 Utilizing cell salvage
 Following Transfusion Triggers

40. Autologous Blood Harvesting
A) Predeposit Autologous Blood Donation( PABD)
A) Acute Normovoluemic Hemodilution (ANH)

41. PABD
 Patients visit 6 weeks in advance to donate
blood
 Blood donation 1 per week
 Blood donation stops 3 weeks before surgery
 Iron therapy is integral to PABD
 No PABD 72 hrs before surgery
 Usually 2 units sufficient

42. Contraindications to PABD
1) If HB < 11 gm /dl
2) More than 6 units reqd
3) Comorbidity e.g cardiac disease
4) Patient having infectious disease markers
Since maximum allowed storage interval for RBC is
6 weeks , hence PABD is executed 6 weeks in
advance.

43. ANH
 Removal of whole blood , replacement with
acellular fluid shortly before anticipated blood
loss
 Done after Induction of Anesthesia and before
start of surgery

44. Advantages of ANH
1) Reduced Absolute RBC loss
2) Unit with patient ; no wrong transfusion
3) No microbiological testing reqd
4) No risk of hemolytic reaction
Caution: Should be restricted to patients with
sufficiently high Hb, who can withstand 1 lt of
whole blood to be taken out and in whom low
target Hb is deemed appropriate

45. Cell Salvage
INTRAOPERATIVE / POSTOPERATIVE
 Shed surgical blood is suctioned under low pressure into a reservoir
filled with saline
 Then washed & filtered & returned to patient
 Can be given upto 6 hrs at room temperature
 Cost effective if loss is > 1000 ml
CONTRAINDICATIONS
 Malignancy
 Leakage of bowel contents in surgical field

46. Pharmacological Blood Sparing
Strategies
ERYTHROPOIETIN- 300 U /kg x14 days
or 600 U / kg thrice a week
APROTININ ( Serine protease inhibitor) – 2 million loading
0.5 million units / hr
High risk of Anaphylaxis to reexposure
TRANEXAMIC ACID – 10 – 15 mg / kg prior to release of tourniquet
DESMOPRESSIN – Mainly for Haemophilia, Von Willebrand disease
FIBRINOGEN – ( Combination of bovine thrombin & human
fibrinogen)

47. Adverse Transfusion
Events
Classified into
Immediate
Delayed

48. Immediate
 Further divided into
A – Immunological
1) Haemolytic transfusion reaction
2) Febrile nonhemolytic transfusion reaction
3) Allergic reactions
4) Anaphylaxis
5) TRALI

49. Immediate
B - Non Immunological
1) Bacterial contamination
2) Circulatory overload
3) Metabolic complications
4) Non immune haemolysis

50. Delayed
A – Immunological
1) Delayed haemolytic tranfusion reaction
2) TAGVHD
3) Post transfusion Purpura (PTP)
4) Alloimmunization
B - Non Immunological
1) Iron overload
2) Transfusion transmitted diseases

51. Acute Haemolytic Transfusion
Reactions
1) Intravascular Haemolysis
2) Extravascular Haemolysis
3) DIC
4) Renal failure

52. Intravascular Haemolysis (IVH)
 Mediated by classical pathway of Complement system
Signs
 Sudden drop in B.P
 Haemoglobinuria
 Haemoglobinaemia
 No rise in haematocrit

53. Extravascular Haemolysis (EVH)
 Antibody mediated or Complement mediated cell destruction
in RE system
 Generally life threatening
Signs
 Falling Haematocrit
 Increased unconjugated bilirubin
 Abnormal peripheral smear
a ) Polychromasis
b) Spherocytes
 May lead to I/V heamolysis

54. Extravascular Haemolysis (EVH)
CAUSE
 Exposure to patient through previous
- Pregnancy
- Transplant
- Transfusion
 Generation of antibodies in response to incompatible Antigens

55. Febrile Nonhemolytic Transfusion
Reaction
Most common Adverse effects
 Increase in temperature of > 10c over base line during transfusion
Cause
1) Formation of Antibodies in recipients against donor WBCs and
Platelets
2) Release of bioactive substances like Interleukins, Cytokines in
the blood

56. Transfusion Related Acute Lung
Injury ( TRALI)
 Rapid onset of respiratory distress, noncardiogenic
pulmonary edema and hypoxia occuring during or soon
after transfusion
CAUSE
Due to the presence of
A) Anti HLA antibody in the plasma of donor
B) Antigranulocyte antibody in the plasma of donor leads
to complement activation and increased pulmonary
vascular permeability
Agent - Any plasma containing blood product

57. TRALI
Definition
New acute lung injury occurring during or within 6
hours post transfusion with a clear temporal
relationship to the transfusion
North American European Consensus Conference
Criteria
 Acute Hypoxemia
 PaO2/ fiO2 ≤ 300 mm Hg
 B/L infilterates in the absence of circulatory overload
 Edema fluid to plasma protein ratio > 0.6

58. Limitations
1) Not possible to differentiate between ALI and TRALI
2) No specific lab tests
3) Limit of 6 hrs may exclude cases developing later
Treatment
On the lines of ARDS

59. Anaphylactic Reactions
 More commonly observed in
Patients of hereditary IgA deficiency
Patients having IgG antibodies to infused
allergens
Remedy
Saline washed RBCs for future transfusions

60. Immediate Immunological
Reactions
 CLINICAL PRESENTATION
 Chills with fever, nausea, chest tightness
 Pain at I/V site, abdomen, joints
 Tachycardia, tachypnea
 Hypotension, diffuse bleeding
 Shock, renal failure
 CLINICAL PRESENTATION UNDER ANAESTEHSIA
 Hypotension
 Dark urine
 Generalized ooze

61. Immediate Immunological
Reactions
Lab Diagnosis
 Send blood back for repeat typing and cross match
 Rising serum bilirubin
 Urine for heamoglobinuria
 Chest X ray if TRALI is suspected

62. Immediate Immunological Reactions
Management
 Oxygen by face mask/ Intubation (TRALI)
 Catheterization
 Continuous vital monitoring
 Furosemide (if BP normal)
 Epinepherine/ corticoids if anaphylaxis suspected
 Maintain urine output between 30-100ml/hr

63. Aquired Diseases
 Incidence getting less due to effective screening
 HIV 1 & 2
 Hepatitis B & C
 Syphilis
 CMV
 Lyme
 Malaria
 Filaria

64. TA GVHD
 Due to transfused immunocompetent lymphocytes
against immunocompromised host
 Rapid course
 Average mortality- 90 %
 Treatment – Gamma irradiated blood products by
exposing WBC’s to 1500 rad to 5000 rad
 Not much effect on RBC’s
 Platelet survival decreases by 30 % at higher doses

65. Metabolic Complications
 Clinically significant depletion of coagulation
proteins & platelets occur in stored blood leading
on to
- Hypothermia
- Hyperkalaemia
- Hypocalcemia
- DIC
 8 – 10 units of red cells infused in a patient may
lead to fall in the level of coagulation proteins to
25 % of normal

66. Delayed Hemolytic Transfusion
Reactions
 Occuring > than 24 hrs post transfusion
 Previous transfusion primes the patient
Signs & Symptoms
 Within 4 – 14 days of transfusion
 Progressive unexplained fall in hemoglobin
 Low grade fever
 Unconjugated hyperbilirubinemia
Treatment
 Self limiting till clearing of all RBC’s

67. Post Transfusion Purpura
 More in females
 5 – 9 days post transfusion
 Due to platelet specific alloantibodies
Treatment
 High dose IV IgG( 2 gm/ kg over 5 days)
 Platelet transfusion though not effective may be required
for bleeding
 Steroids ?
 Plasma exchange?

68. Massive Blood
Transfusion(MBT)
 Replacement of one blood mass in a period of 24 hrs
 Transfusion of 4 or more red cell concenterates with
in 1 hr
 Replacement of 50% of total blood volume with in 3
hrs
 Rate of infusion > 1 unit in 10 minutes
Indication
 Hypovolemic shock secondary to blood loss

69. Complications Of MBT
Physical
 Hypothermia
 Hemodilution
 Metabolic
- Hyperkalemia –Plasma K+ levels in the stored blood
increased by 1 mEq/ l /day
- Citrate toxicity(3 gm / unit)
- Acidosis
- Alkalosis( 1 ml citrate = 3 mEq HCO3)

70. Complications Of MBT
Physiological
 Left shift of ODC
 Decrease of labile coagulation factors
 Dilutional Thromocytopenia

71. Citrate Toxicity
 May lead to Hypocalcaemia
 Look for total calcium : ionized calcium ratio
(Normal 2:1)
 If low give 10 – 20 ml 10 % calcium gluconate

72. Thank you