blood components therapy

Dr. P. Sivaraj MD DA
Govt Villupuram Medical College
and Hospital

Blood component therapy
• Optimizes the resources
• Avoids constituents harmful effects
• Specific replacement

Indications
• Perioperative blood component therapy
accounts for 23% of transfusions.
• General –
– Inadequate oxygen delivery
– Comorbidity, acuity of anaemia and ability to
compensate

Definitions
• Blood product :
Any therapeutic substance prepared
from human blood.
• Whole blood:
Unseparated blood collected into an
approved container containing an
anticoagulant-preservative solution.

Scheme for separation of whole
blood for component therapy

Comparison of whole blood
and packed red blood cells
Value Whole Blood PRBC
• Volume (mL) 517 300
• Erythrocyte mass (mL) 200 200
• Hematocrit (%) 40 70
• Albumin (g) 12.5 4
• Globulin (g) 6.25 2
• Total protein (g) 48.8 36
• Plasma sodium (mEq) 45 15
• Plasma potassium (mEq) 15 4
• Plasma acid (citric-lactic) 80 25(mEq)
• Donor-to-recipient ratio 1 unit per patient 4-6 patients

Properties of whole blood and packed
red cell concentrates stored in cpda

Blood component
1. A constituent of blood, separated from whole
blood, such as:
 Red cell components
2. Plasma or platelets
3. Cryoprecipitate, prepared from fresh frozen
plasma, which is rich in Factor VIII and
fibrinogen

Red cell components
• Red cell concentrate
• Red cell suspension (red cells + additive
solution)
• Buffy coat depleted red cells
• Leucocyte-depleted (filtered) red cells

Plasma derivative
Human plasma proteins prepared are:
 Albumin
 Coagulation factor concentrates
 Immunoglobulins

Whole blood
• Fresh whole blood
1. Warm
2. 450ml+63 ml CPDA(>60KG), 350+49 ml CPDA
3. 1.5 -4 lakhs platelets
4. 100% coagulation
5. 1500mg fibrinogen
• Restores –
1. Blood volume
2. Hemoglobin
3. Platelets
4. Coagulation factors

Whole blood
Advantages
• Simple and inexpensive
• No special equipment
• Red cells, volume and stable coagulation factors.
Disadvantages
• Circulatory overload
• Donor availability
• Screening time
• Infection risk

Whole blood
• Storage Between +2°C and +6°C
• May be stored up to 35 days if collected in a
suitable anticoagulant such as citrate
phosphate dextrose with added adenine
[CPDA]
• During storage at +2°C to +6°C, changes in
composition occur resulting from red cell
metabolism

Whole blood
Indications
• Red cell replacement in acute blood loss with
hypovolaemia
• Exchange transfusion
• Patients needing red cell transfusions where red cell
concentrates or suspensions are not available
Contraindications
Risk of volume overload in patients with:
• Chronic anaemia
• Incipient cardiac failure

Packed red cells
• Concentrated to a hematocrit of about 75%
• volume is made to 200 ml.
• Giving packed red cells is the fastest way to
increase the oxygen-delivering capacity of the
blood.
• A unit of packed red cells will raise the
hematocrit by 3% and the haemoglobin by 1
gm/dl.

RED CELL SUSPENSION
• 150–200 ml red cells with minimal residual
plasma to which approximately 110 ml normal
saline, adenine, glucose, mannitol solution
(SAG-M) or an equivalent red cell nutrient
solution has been added
• Haemoglobin approximately 15 g/100 ml
• Haematocrit 50–70%
Contraindications
• Exchange transfusion of neonates.

RED CELL SUSPENSION
Advantages
• Reduces viscosity and is therefore easier to
infuse
• Longer shelf life than whole blood or red cell
concentrate
• Permits the use of the separated components
(plasma/platelets) for other patients.
Disadvantages
• Cost
• Expensive equipment.

Buffy coat’ depleted red cells
• Requires controlled centrifugation
• The white cells (and most of the platelets)
remain in a layer called the ‘buffy coat’
which forms an interface between the red
cells and the plasma.

Buffy coat’ depleted red cells
Advantages
• 10% of the white cells in red cell concentrate
• Less risk of transfusion reactions
• Used to prepare platelet concentrates.
Disadvantages
• Costly
• Special blood packs and equipment are
required
• More skill and operator training is needed.

Washed red cells or micro-
aggregate free blood
• RBCs are washed and suspended in sterile
saline
• Hematocrits of 70–80%
• Volume of approximately 180 ml.
• Saline washing –
1.Performed at any time during the shelf-life
2.Plasma (98%),
3.Reduces the concentration of leukocytes and
4.Removes platelets and cellular debris
5.Stored for only 24 h at 1–6°C.

Irradiated red cells
• Gamma irradiation- 90% Cesium 137, 10%
Cobalt 60
• Damage to WBC DNA
• Prevents GVHD.
• Immuno-compromised patients, lymphoma
patients, stem-cell/marrow transplants and
intrauterine transfusion.

Leukocyte depleted red cells
• 99.9% of the white cells are filtered out
(pre- or post-storage) or removed by
freezing/thawing/washing.
• Becoming very popular.
• These reduce (but do not eliminate) the risk
of cytomegalovirus (CMV), Epstein-Barr,
human T-lymphotropic virus (HTLV)
infections and febrile reactions.

Red Cell Substitutes
• There are different types of red cell
substitutes currently being studied.
• The goal is to enhance the oxygen-carrying
capacity for patients.
• Useful in patients who refuse blood
transfusion or in situations where blood is
not readily available.

Haemoglobin-Based Oxygen
Carriers
• These are purified cell-free hemoglobins
• Globulin portion of the molecule has been
modified chemically by conjugation, cross-
linking or polymerization.
• Modification increases the oxygen-releasing
ability of the haemoglobin.
• The bovine Hemoglobin-Based Oxygen
Carriers (HbOCs) has completed phase III
clinical trials

Perfluorocarbon-Based Red Cell
Substitutes
• These consist of carbon backbones highly
substituted with fluorine.
• They can dissolve large amounts of oxygen.
• The perfluorocarbons are biologically inert;
however, the phospholipids are required to emulsify
them.
• The only perfluorcarbon that remains in clinical
trials is Oxygent, an emulsion of perfluoro-ocytl
bromide and egg yolk phospholipid.
• Oxygent is being studied for use in perioperative
period to allow more extensive hemodilution.

Transfusion trigger
• Level at which a surgical patient needs
blood transfusion

Recommendations- The ASA
Task Force 2006
• A close watch on assessment of blood loss
during surgery and assessment of tissue
perfusion is to be maintained.
• Transfusion is rarely indicated when the
haemoglobin concentration is greater than 10
gm/dl, and is almost always indicated when it is
less than 6 gm/dl.
• For intermediate haemoglobin concentrations
(6–10 gm/dl), transfusion based on the patient's
risk for inadequate oxygenation.

Recommendations- The ASA Task
Force 2006
• Use of a single haemoglobin “trigger” for all
patients and other approaches that fail to consider
all important physiologic and surgical factors
affecting oxygenation are not recommended.
• When appropriate, preoperative autologous blood
donation, intraoperative and postoperative blood
recovery, acute normovolemic hemodilution and
measures to decrease blood loss (deliberate
hypotension and pharmacologic agents) may be
beneficial.

Platelets
• Platelets are used in the perioperative
setting, when a quantitative or qualitative
platelet defect is the suspected cause of
bleeding.
Normal values:
• Adult = 1.5- 4 lakhs/mm3
• Newborn = 250,000/mm3
.

Collection and Storage
Pooled Platelets
• Obtaining a “pooled platelet” preparation is
a two-step procedure.
• First, one unit of platelets is harvested from
a unit of whole blood.
• Then, four to six of these individual units
(from different donors) are “pooled”
together in a single pack.

Pooled Platelets
• Each bag containing 5000- 8500/mm3
platelets with 50–70 ml of residual plasma
volume.
• Disadvantage
1.Exposure to multiple donors
2.Contains 108
– 109
WBCs
3.Platelets expires 4 hours after pooloing

Apheresis Platelets
• Collected from a single donor
• Blood cycles through the apheresis machine-
4000 to 5000 ml/ 1.5 to 2 hrs
• Units contain 3×1011
to 4×1011
platelets
• The amount of platelets collected with this
procedure is equivalent of four to six units of
random donor platelets.

Dosage
• One platelet concentrate will raise the platelet
count in an adult by 7,000–10,000/mm3
at 1 hr
in 70kg
• In children, 0.1–0.2 units/kg will increase the
platelet count by 30–50,000/cumm.
• Increased consumption is seen in sepsis,
splenomegaly, platelet antibodies or
chemotherapy.

Platelets
• Leukocyte depleted platelets
1.Platelet pheresis
2.Prevents FNHTR
3.Reduction of HLA alloimmunisation, CMV,
immunomodulaion
• Irradiated platelets- ultra violet B
1.GVHD

ASA Task Force provided the
following recommendations:
1. Prophylactic platelet transfusion is
ineffective and rarely indicated when
thrombocytopenia is due to increased
platelet destruction (e.g., idiopathic
thrombocytic purpura).
2. Prophylactic platelet transfusion is
rarely indicated in surgical patients with
thrombocytopenia because of decreased
platelet production

ASA Task Force provided the
following recommendations:
3. Surgical and obstetric patients with microvascular
bleeding usually require platelet transfusion if the
platelet count is less than 50 lakhs /mm3
4. Vaginal deliveries or operative procedures
ordinarily associated with insignificant blood loss
5. Platelet transfusion may be indicated despite an
apparently adequate platelet count if there is known
platelet dysfunction and microvascular bleeding.

Platelet Products and
Substitutes
Cryopreserved platelets
• Platelets suspended in dimethylsulfoxide (DMSO)
at –80°C have been preserved up to 10 years.
• During the thawing and post-thaw processing,
develop functional and morphologic defects.
• Because of the complexities of storing, processing
and thawing frozen platelets, the current use is
limited.

Lyophilized platelets
• Lyophilized platelets- paraformaldehyde
solution and then freeze-dried.
• Specific advantages of this product include
1. storage measured in years instead of days,
2. reduced storage space and true sterility.
• Once rehydrated, they appear to retain
structural integrity and attach only to
damaged subendothelial surfaces.

Infusible Platelet Membranes
(IPMs)
• Infusible Platelet Membranes (IPMs) are
manufactured from outdated platelet units.
• Platelet-derived microparticles (microvesicles)-
collection and processing of components.
• They appear to have the ability to function as a
platelet - primary hemostatic plug.
• One application for IPMs may be in patients who
are refractory to platelet transfusions and for whom
(HLA)-matched platelet apheresis donors is
difficult.
• Disadvantage- relatively short life (less than 24 h) in
vivo.

Plasma
FFP
• Contain all plasma protein, sodium, phosphates and
some glucose
• FFP is used primarily to provide replacement
coagulation factors.
• Concentration of coagulation factor- 0.6 to 1.4IU/ml
• Plasma cholinesterase

Collection, Storage and
Transfusion
• Frozen plasma (FP) is prepared from whole
blood by separating and freezing the
plasma (200–250 ml) within 6 h of donation.
• It may be stored for up to 1 year at –18°C
or lower.
• Maintain atleast 70% normal level of labile
factors

FFP
• The FFP should be thawed between 30 and
37°C with constant agitation.
• After thawing, it may be stored at 2 – 6 0
C for
upto 24 hrs.
• 4 to 6 platelet concentrates, one unit single-
donor aphaeresis platelets or one unit fresh
whole blood provide a quantity of coagulation
factors similar to that contained in 1unit FFP.

FFP
• Therapeutic dose of FFP = 10–15 ml/kg [to achieve a
minimum of 30% of plasma factor activity], except
for urgent reversal of warfarin anticoagulation, for
which 5–8 ml/kg FFP will usually suffice.
• Whenever depletion of coagulation factors is
considered to be clinically important, 800–2,000 ml
(four to eight packs of FFP) in a 70-kg adult for
each blood volume lost should be given over 90–120
min.
• Slower rates of infusion or smaller volumes of FFP
are probably ineffective.

Indications
• FFP is indicated for use in-
– Bleeding patients with multiple coagulation
factor deficiencies secondary to liver disease,
– Disseminated intravascular coagulation (DIC)
and
– Dilutional coagulopathy resulting from massive
blood or volume replacement

Indications
It is also indicated for patients with
• congenital factor deficiencies such as deficiencies of
Factor V or XI.
• FFP is also used along with plasmapheresis in the
treatment of thrombotic thrombocytopenic purpura
(TTP) and haemolytic uremic syndrome.
• FFP should not be used as a source of protein for
nutritionally deficient patients or as a volume expander.

Recommendations:
• Urgent reversal of warfarin therapy
• Correction of known coagulation factor deficiencies
• Correction of microvascular bleeding in the
presence of elevated (>1.5-times normal)
prothrombin time (PT) or partial thromboplastin
time (PTT)
• Correction of microvascular bleeding secondary to
coagulation factor deficiency in patients transfused
with more than one blood volume and when PT and
PTT cannot be obtained in a timely fashion

Recommendations:
• Heparin resistance in pts receiving
unfractionated heparin
• FFP should be given in doses calculated to
achieve a minimum of 30% of plasma factor
concentration
• FFP is contraindicated for augmentation of
plasma volume or albumin concentration
• FFP should not be used to reconstitute packed
RBCs
• FFP should not be used as a source of proteins
or routinely after cardiopulmonary bypass

Cryoprecipitate
• Contains 100 antihemophilic units (AHU) and 250 mg of
fibrinogen.
• It is thawed at 37°C and administered through a standard blood
filter and as rapidly as possible- 200 ml/hr within 6 hrs of thaw
• Contain fibrinogen, fibronectin, vWF,VIII,XIII.
• 1 unit of plasma – 10 to 20 ml of cryoprecipitate
• Dose- adult- 5 bags
• Frozen at -200
C

Indications
1. Microvascular bleeding with hypofibrinogenemia
• DIC with fibrinogen < 80-100 mg/dl
• Hemorrhage or massive transfusion with fibrinogen <
100-150 mg/dl
1. Prophylaxis in hemophilia A and vWD
2. Prophylaxis in congenital dysfibrinogenemia
• One unit of cryoprecipitate per 10 kg body weight
raises the plasma fibrinogen concentration by
approximately 50 mg/dl in the absence of continued
consumption or massive bleeding.

Cryoprecipitate Reduced Plasma
• Cryoprecipitate Reduced Plasma (CRP) is the
plasma remaining once the cryoprecipitate has
been prepared.
• Contain vWF enzyme- degrade the existing
multimers.
• Therapeutic plasma exchange (TPE) is the only
disease in which the component is used as
therapeutic treatment

Virus ‘inactivated’ plasma
• Methylene blue/ultraviolet light- to reduce the
risk of HIV, hepatitis B and hepatitis C.
• The ‘inactivation’ of other viruses, such as
hepatitis A and human parvovirus B19 is less
effective.
• The cost of these products is considerably
higher than conventional fresh frozen plasma.

Fibrin Glue
• Two main components, i.e. fibrinogen and
thrombin.
• The thrombin converts the fibrinogen to
fibrin by enzymatic action.
• The concentrated thrombin solution
produces a fibrin clot in about 10s.
• Both the extrinsic and the intrinsic
mechanisms of blood coagulation are
bypassed with the use of fibrin glue.

Plasma derivatives containing factor
IX
Prothrombin Complex Concentrate (PCC)
• Koyne, Proplex
• Factor IX is recovered – ion exchange or inorganic
chemicals
• Bebuin VH- vit k
• Description Contains: PCC Factor IX
• Factors II, IX and X
• Some preparations also contain Factor VII
• Usually about 350–600 i.u. of Factor IX
• Infection risk As Factor VIII
• Storage As Factor VIII

Prothrombin Complex Concentrate
• Indications
1. Treatment of haemophilia B (Christmas disease)
2. Immediate correction of very prolonged
prothrombin time
• Contraindications
1. PCC not advised in patients with liver disease or
thrombotictendency

Fibrinogen concentrate
• Derived from human plasma
• Potential to improve hemostasis more rapidly
• Low risk of immunologic reactions, infections and
intra vascular volume overload
• Single dose of 4gm- 200mg/dl of fibrinogen
• Reduces platelets admin and number of donor
exposure

Plasma Protein Fractions
• Albumin – 5% & 25%
• α & β Globulin
• Volume expanders
• No coagulation factors
• Given without ABO Rh typing
• Very expensive
• Short supply
• Bacterial sepsis- albumin- < 4hrs

Recommendations for Preadmission Patient
Preparation
• Erythropoietin with or without iron may be
administered when possible to reduce the need for
allogeneic blood in selected patient populations (e.g.,
renal insufficiency, anemia of chronic disease,
refusal of transfusion).
• Administer iron to patients with iron deficiency
anemia if time permits.
• In consultation with an appropriate specialist,
discontinue anticoagulation therapy (e.g., warfarin,
anti-Xa drugs, antithrombin agents) for elective
surgery.

Preparation
• Transition to a shorter acting drug (e.g., heparin,
low-molecular-weight heparin) may be appropriate
in selected patients.
• If clinically possible, discontinue nonaspirin
antiplatelet agents (e.g., thienopyridines such as
clopidogrel, ticagrelor, or prasugrel) for a
sufficient time in advance of surgery, except for
patients with a history of percutaneous coronary
interventions.
• Aspirin may be continued on a case-by-case
basis.

Preparation
• The risk of thrombosis versus the risk of increased
bleeding should be considered when altering
anticoagulation status.
• Assure that blood and blood components are
available for patients when significant blood loss or
transfusion is expected.
• When autologous blood is preferred, the patient may
be offered the opportunity to donate blood before
admission only if there is adequate time for
erythropoietic reconstitution.

Recommendations for Preprocedure
Preparation
• Blood Management Protocols.
• Multimodal protocols or algorithms may be
employed as strategies to reduce the usage of blood
products.
• A restrictive red blood cell transfusion strategy may
be safely used to reduce transfusion administration.
– The determination of whether hemoglobin
concentrations between 6 and 10 g/dl justify or
require red blood cell transfusion should be
based on potential or actual ongoing bleeding
(rate and magnitude), intravascular volume
status, signs of organ ischemia, and adequacy of
cardiopulmonary reserve.

Recommendations for Preprocedure Preparation
– Red blood cells should be administered unit-by-
unit, when possible, with interval reevaluation.
• A protocol for avoidance of transfusion may be used
as a strategy to reduce blood loss for patients in
whom transfusion is refused or is not possible.

• A massive (i.e., hemorrhagic) transfusion
protocol may be used when available as a
strategy to optimize the delivery of blood
products to massively bleeding patients.
• Use a maximal surgical blood order schedule,
when available and in accordance with your
institutional policy, as a strategy to improve
the efficiency of blood ordering practices.

• Reversal of Anticoagulants
• For urgent reversal of warfarin, administer PCCs in
consultation with the appropriate specialist, or
administer FFP.
• Administer vitamin K for selected patients for
nonurgent reversal of warfarin, except when rapid
restoration of anticoagulation after surgery is
required.
• Antifibrinolytics for Prophylaxis of Excessive Blood
Loss.
• Use antifibrinolytic therapy for prophylaxis of the
use of allogeneic blood transfusion in patients
undergoing cardiopulmonary bypass.

Preparation
• Antifibrinolytics for Prophylaxis of Excessive Blood
Loss.
• Use antifibrinolytic therapy for prophylaxis of the
use of allogeneic blood transfusion in patients
undergoing cardiopulmonary bypass.
– Consider using antifibrinolytic therapy for
prophylaxis in certain orthopedic procedures
such as knee replacement surgery.
– Consider using antifibrinolytic therapy for
prophylaxis in liver surgery and other clinical
circumstances at high risk for excessive bleeding.

Preparation
• Acute Normovolemic Hemodilution (ANH).
• Consider ANH to reduce allogeneic blood
transfusion in patients at high risk for
excessive bleeding (e.g., major cardiac,
orthopedic, thoracic, or liver surgery), if
possible.

Recommendations for Intraoperative and Postoperative
Management of Blood Loss
• Allogeneic Red Blood Cell Transfusion.
• Administer blood without consideration of duration of storage.
• Leukocyte-reduced blood may be used for transfusion for the
purpose of reducing complications associated with allogeneic
blood transfusion.
• Reinfusion of Recovered Red Blood Cells.
• Reinfuse recovered red blood cells as a blood-sparing
intervention in the intraoperative period, when appropriate.

• Intraoperative and Postoperative Patient Monitoring.
• Periodically conduct a visual assessment of the surgical field
jointly with the surgeon to assess the presence of excessive
microvascular (i.e., coagulopathy) or surgical bleeding.
• Use standard methods for quantitative measurement of blood
loss, including checking suction canisters, surgical sponges,
and surgical drains.
• Monitor for perfusion of vital organs using standard ASA
monitors (i.e., blood pressure, heart rate, oxygen saturation,
electrocardiography) in addition to observing clinical
symptoms and physical exam features.

– Additional monitoring may include
echocardiography, renal monitoring (urine
output), cerebral monitoring (i.e., cerebral
oximetry and NIRS), analysis of arterial blood
gasses, and mixed venous oxygen saturation.
• If anemia is suspected, monitor
hemoglobin/hematocrit values based on estimated
blood loss and clinical signs.
• If coagulopathy is suspected, obtain standard
coagulation tests (e.g., INR, aPTT, fibrinogen
concentration) or viscoelastic assays (e.g., TEG and
ROTEM), if available, as well as platelet count.

– During and after transfusion, periodically check for
signs of a transfusion reaction including hyperthermia,
hemoglobinuria, microvascular bleeding, hypoxemia,
respiratory distress, increased peak airway pressure,
urticaria, hypotension, and signs of hypocalcemia.
– If signs of a transfusion reaction are apparent,
immediately stop the transfusion, give supportive
therapy, and initiate supportive care.
– Notify the blood bank of the transfusion reaction case.

• Treatment of Excessive Bleeding.
• In patients with excessive bleeding, the following
recommendations are made based upon the
evidence for each of these interventions when
studied singly or when compared with placebo. The
impact of combinations of these interventions is not
addressed in these Guidelines.

– Obtain a platelet count before transfusion of
platelets, if possible.In addition, obtain a test of
platelet function, if available, in patients with
suspected or drug-induced (e.g., clopidogrel)
platelet dysfunction.

– Obtain coagulation tests (i.e., PT or INR and aPTT)
before transfusion of FFP, if possible
– Assess fibrinogen levels before the
administration of cryoprecipitate, if possible.

– Desmopressin may be used in patients with
excessive bleeding and platelet dysfunction.
– Consider topical hemostatics such as fibrin glue
or thrombin gel.
– Consider the use of antifibrinolytics (i.e., ε-
aminocaproic acid, tranexamic acid) if fibrinolysis
is documented or suspected and if these agents
are not already being used.

– PCCs may be used in patients with excessive
bleeding and increased INR.
– Consider recombinant activated factor VII when
traditional options for treating excessive bleeding
due to coagulopathy have been exhausted.
– Fibrinogen concentrate may be used.

ASA transfusion guidelines
Products Usually indicated Not usually
indicated
RBCs < 6gdl-1
> 10gdl-1
FFP
PT/aPTT > 1.5 times
normal
PT/aPTT< 1.5 times
normal
Platelets
< 50000 > 100000
Cryoprecipitate
Fibrinogen < 80-100
mg/dl
Fibrinogen > 80-100
mg/dl

blood components therapy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to blood components therapy

Similar to blood components therapy (20)

Recently uploaded

Recently uploaded (20)

blood components therapy