blood grouping, blood transfusion and reactions

1. BLOOD GROUPS AND
BLOOD TRANSFUSIONS
BY DR. MANJEET SHINDE

2. RED BLOOD CELLS
• Also known as erythrocyte.
• A major function of RBCs is to
transport haemoglobin, which in turn,
carries oxygen from lungs to the tissues.
• Normal RBC are biconcave disk like
having a mean diameter of about 7.8µm
and a thickness of 2.5µm at the thickest
point and 1µm or less in the centre.

3. • Life span 120 days.
• The shape of RBCs can change remarkably as the cells squeeze
through the capillaries; it can be assume as a “bag” that can be
deformed into almost any shape.
• Provide intravascular volume and O2 carrying capacity.
• Transfusion of red cells can be life saving in situations in situations of
acute intravascular volume loss eg trauma, surgery.

4. • Although red cells have a limited life span, transfusion to another
individual is a form of tissue transplantation, with similarities to
kidney, heart and bone marrow transplantation.
• Compatibility between donor recipient is vital or rejection will occur.

5. Blood type
• ABO blood group genetic locus has three alleles, which means three
different forms of same gene.
• These three alleles IA, IB, IO determines the three blood types, we
typically call these alleles “A” “B” and “O”.
• The type O allele is almost functionless, so it causes no significant
type O agglutinogen on the cells. Conversely, the type A and type B
alleles do cause strong agglutinogens on the cells.
• Thus, the O allele is recessive to both A and B alleles, which shows
co-dominance.

6. • Blood types with their genotypes and their constituent agglutinogens
and agglutinins.
• There are 6 possible combination of alleles OO, OA, AA, OB, BB, AB.
These combinations of alleles are known as the genotype and each
person is one of six.
Genotype Blood types Agglutinogens Agglutinins
OO O – Anti-A and Anti-B
OA or AA A A Anti-B
OB or BB B B Anti-A
AB AB A and B –

7. • Relative Frequencies of different blood types
1. O – 47%
2. A – 41%
3. B – 9%
4. AB – 3%

8. Group O
• Approximately 45% of the population is group
O.
• No A or B antigen present, think of as “O”
antigen present.
• These individuals forms potent anti-A and anti-
B antibodies
which circulate in blood plasma at all times.

9. Group A
• Approximately 41% of the population is group
A.
• No B antigen present.
• These individuals form potent anti-B antibodies
which circulate the blood plasma at all times.

10. Group B
• Approximately 9% of the population is a
group B.
• No A antigen present.
• These individuals form potent anti-A
antibodies which circulate in the blood
plasma at all times.

11. Group AB
• Approximately 3% of the
population is a group AB.
• Both A and B antigens present.
• These individuals possess no
ABO antibodies.

12. BOMBAY BLOOD GROUP
• It is also called the HH group. The peculiarity is that they do not
express the H antigen.
• As a result they cannot from A antigens or B antigens on the red
blood cells.
• Thus they can donate blood to anybody with ABO grouping but
can receive blood only from Bombay blood group people.

13. RH factor
• In addition to having A, B or both red cells also contain the RH
antigen.
• It is found on the erythrocytes of most people.
• This antigen was first isolated & identified in Rhesus monkey.
• Rh positive meaning that the Rh antigen is present.
• It is important to know the Rh factor when crossmatching blood for
transfusion.

14. • Also, a very important Rh problem can occur with a pregnant women.
• If a Rh negative mother have a Rh positive baby, then antibodies can
build up against the Rh + blood. This is called as Erytheroblastosis
fetalis.
• This is not usually a big problem for the first baby, but it could cause
problem with a future pregnancy.

15. INTERPRETATION OF SLIDE TYPING TESTING WITH ANTI-A
ANTI-SERUM
• If an RBC contains the A antigen the red
blood cells will be agglutinated by anti-
A, a positive reaction.
• If an RBC does not have the A antigen
there will be no clumping, a negative
reaction.

16. INTERPRETATION OF SLIDE TYPING TESTING
WITH ANTI-B ANTI-SERUM
• If an RBC contains the B antigen the red
blood cells will be agglutinated by anti-
B, a positive reaction.
• If an RBC does not have the B antigen
there will be no clumping by anti-B, a
negative reaction.

17. SLIDE BLOOD TYPING GROUP O
• The left hand of the slide contains anti-A does not react with Red
blood cells.
• The right hand side of the slide contains anti-B does not react with
the Red blood cells.

18. SLIDE BLOOD TYPING GROUP AB
• The left hand side of the slide contains anti-A which reacts with Red
blood cells.
• The right hand side of the slide contains anti-B which reacts with the
red blood cells.

19. BLOOD TRANSFUSION
• Blood transfusion is a vital part of the modern health care system
without which efficient medical care is not possible.
• The aim of blood transfusion is to provide effective blood and
blood products, which are as safe as possible, and adequate to
meet patient’s need.

20. Blood for transfusion is considered safe
when it is:
• Donated by a carefully selected, healthy donor.
• Free from infections that could be harmful to the recipient.
• Processed by reliable methods of testing, component production, storage and
transportation.
• Transfused only upon need and for the patient’s health and wellbeing.

21. Types of blood donors
• Voluntary Donors – Donate Blood on their own
• Replacement Donors : from within the patient’s own family or community
• Autologous Blood Donor -Are patients who donate their own blood for self
• Apheresis Donor- Donate blood components through the process of cell
separation

22. SCREENING
• It is the process that starts with the recruitment of safe blood donors and is
followed by the mandatory screening for five transfusion transmissible infections
(TTIs) which includes HIV, Hepatitis B, Hepatitis C, syphilis and malaria.
• Safe Blood Transfusion Act 2002, which states that prior to transfusion, all blood
and its products must undergo testing.

23. The donor screening process has four major aspects
1. Registration, consent, Demographic information. (taken to inform)
2. Medical history
Salient demographic information include
 Donor’s full name
 Father’s/husband’s name
 Date of birth/ Age
 Gender – male/female
 Residential and official address with number

24. 2. Medical History

28. • HIV Infection / AIDS: Permanently defer
• Malaria
• History of malaria in endemic area but duly treated and free from any symptoms
treatment : Accepted 3 months after
• Syphilis
• Genital sore or generalized skin rashes disappear & completion of therapy: Defer for 12 month after rashes
• Tuberculosis Defer for 5 years after cessation of symptoms and treatment
3. LABORATORY TESTS
a) Hb/CBC
b) ABO and Rh blood grouping

29. 4. PHYSICAL EXAMINATION
(The donor should be in good health & Light meals before donation)
1) Age : 18 – 60 years
2) Weight : > 45 kg can donate 350 ml
55 kg can donate 450 ml
3) Gender : Male or female
4) Hb / Hct : > 12.5 g/dl or > 38%
5) BP : Systolic – 100 – 130 mmHg;
Diastolic -80-100 mmHg
6) Pulse : 60-90 beats / min, regular, good volume
7) Temp : Not exceeding 37.50 C
8) Rule out : Lymphadenopathy, Chest, CVS, Abdominal abnormalities.

32. Component
• A blood component is a constituent of blood, separated from whole blood, such as:
• Red cell concentrate (packed RBC)
• Plasma
• Platelet concentrate
• Cryoprecipitate, prepared from fresh frozen plasma; rich in Factor VIII and fibrinogen
• A plasma derivative is made from human plasma proteins prepared under pharmaceutical
manufacturing conditions, such as:
• Albumin
• Coagulation factor concentrates
• Immunoglobulin

33. Whole blood
• 450 mL whole blood in 63 mL anticoagulant‐preservative solution of which Hb will be approximately
1.2 g/dL and haematocrit (Hct) 35‐45% with no functional platelets or labile coagulation factors (V and
VIII) when stored at +2°C to +6°C.
Storage:
• Between +2°C and +6°C in an approved blood bank refrigerator, fitted with a temperature monitor and
alarm.
Indications:
• Red cell replacement in acute blood loss with hypovolaemia.
• Exchange transfusion.
Contraindications:
• Risk of volume overload in patients with: Chronic anaemia and Incipient cardiac failure.
Administration:
• Must be ABO and RhD compatible with the recipient.
• Never add medication to a unit of blood.
• Complete transfusion within 4 hours of commencement.

34. Red cell concentrates [packed red blood cells (PRBC)]
• 150‐200 mL red blood cells from which most of the plasma has been removed. Hb concentration
will be approximately 20 g/100 mL (not less than 45 g per unit) and Hct 55‐75%.
Storage:
• Between +2°C and +6°C in an approved blood bank refrigerator, fitted with a temperature monitor
and alarm.
Indications: Replacement of red cells in anaemic patients.

35. Platelet concentrates (PC)
• PCs are prepared from units of whole blood that have not been allowed to cool below +20°C. A single donor unit consists of 50‐60
mL plasma that should contain ≥55 x 109 platelets.
Storage:
• PCs may be stored for up to 5 days at +20°C to +24°C (with agitation). PCs require continuous agitation during storage, on a
platelet shaker and in an incubator that maintains the required storage temperature.
Dosage:
• 1 unit of platelet concentrate/10 kg; for an adult of 60‐70 kg, 4‐6 single donor units containing at least 240 x 109 platelets should
raise the platelet count by 20‐40 x 109/L. Increment will be less if there is splenomegaly, disseminated intravascular coagulation
(DIC) or septicemia.
Indications:
• Thrombocytopenia.
• Platelet function defects.
• Prevention of bleeding due to thrombocytopenia as in bone marrow failure.
Contraindications:
• Idiopathic autoimmune thrombocytopenic purpura (ITP).
• Thrombotic thrombocytopenic purpura (TTP).
• Untreated DIC.
• Thrombocytopenia associated with septicemia, or in cases of hypersplenism.

36. Fresh Frozen Plasma (FFP)
• FFP is plasma prepared from whole blood, either from the primary centrifugation of
whole blood into red cells and plasma or from a secondary centrifugation of platelet rich
plasma. The plasma is rapidly frozen to –25°C or colder within 8 hours of collection and
contains normal plasma levels of stable clotting factors, albumin, immunoglobulin and
Factor VIII at a level of at least 70% of normal fresh plasma.
Unit of issue:
• 200‐300 mL.
Infection risk:
• Capable of transmitting any agent present in cells or plasma which was undetected by
routine screening TTIs, including HIV, hepatitis B and C, syphilis and malaria.
Storage:
• FFP is stored at –25°C or colder for up to 1 year. Before use, it should be thawed in the
blood transfusion center between +30°C and +37°C.

37. Definite indications:
• Replacement of a single coagulation factor deficiency, where a specific or combined factor concentrate
is unavailable or contraindicated.
• Immediate reversal of warfarin effect where prothrombin complex concentrate is unavailable.
• Thrombotic thrombocytopenic purpura.
• Inherited coagulation inhibitor deficiencies where specific concentrate is unavailable.
• C1 esterase inhibitor deficiency where specific concentrate is unavailable.
Conditional indications:
• Massive blood transfusion.
• Acute DIC if there are coagulation abnormalities and patient is bleeding.
• Liver disease, with abnormal coagulation and bleeding – prophylactic use to reduce prothrombin time
(PT) to 1.6‐1.8 x normal for liver biopsy.
• Cardiopulmonary bypass surgery – use in the presence of bleeding but where abnormal coagulation is
not due to heparin. Routine perioperative use is not indicated.
• Severe sepsis, particularly in neonates (independent of DIC).
• Plasmapheresis.

38. Precautions:
• Acute allergic reactions are not uncommon, especially with rapid infusions.
• Severe life‐threatening anaphylactic reactions occasionally occur.
Dosage: 15 mL/kg.
Administration:
• Should be ABO compatible.
• Infuse as soon as possible after thawing.
• Labile coagulation factors rapidly degrade; use within 6 hours of thawing.
• FFP may be beneficial if PT and/or partial thromboplastin time (PTT) >1.5 times normal.
• FFP for volume expansion carries a risk of infectious disease transmission and other transfusion
• reactions (e.g. allergic) that can be avoided by using crystalloid or colloid solutions.

39. Cryoprecipitated anti‐haemophilic factor (Cryo‐AHF)
Description:
• Cryo‐AHF is prepared from FFP by collecting the precipitate formed during controlled thawing at +4°C and
re‐suspending in 10‐20 mL plasma.
• It is stored at –25°C or colder for up to 1 year after the date of phlebotomy.
• Cryo‐AHF contains about half the Factor VIII and fibrinogen as a pack of fresh whole blood: e.g. Factor VIII:
80‐100 iu/ pack; fibrinogen: 150‐300 mg/ pack.
Indications:
• As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of:
• von Willebrand Factor (von Willebrand’s disease).
• Factor VIII (haemophilia A).
• As a source of fibrinogen in acquired coagulopathies; e.g. DIC.
• Can be used in isolated Factor XIII deficiency.

40. BLOOD TRANSFUSION REACTION
• Transfusion of blood and its product is, ordinarily a safe and effective
way of correcting hematological defects but adverse effects do occur
during or after transfusion and they are commonly called blood
transfusion reactions.

41. Categories of transfusion reactions
• Immunological reactions
• Non-Immunological reactions
• Acute ( onset within less than 24 hours)
• Delayed ( onset within days or months)

42. Immunological reactions
Acute ( onset within less than 24 hours)
• Hemolytic (mostly ABO incompatibility)
• Febrile non-hemolytic
• Transfusion Related Acute Lung Injury (TRALI), antibody in donor plasma against patient’s leukocytes
• Allergic (allergens in donor blood)
• Anaphylactic (possibly IgA related)

43. Immunological reactions
Delayed ( onset within days or months)
• Hemolytic ( antibody present)
• Alloimunization: immune response to nonself antigens from members of the same species, which are called
alloantigens or isoantigens
• Transfusion-associated graft-versus-host disease
• Post-transfusion purpura
• Immunomodulation: regulatory adjustment of the immune system

44. Non-Immunological reactions
ACUTE DELAYED
Bacterial contamination Transfusion induced hemosiderosis
Circulatory overload Disease transmission
1. Hepatitis B & C
2. HIV 1 & 2
3. Syphilis
4. Malaria
5. CMV
6. HTLV-1
Physical or chemical hemolysis
Hyperkalemia

45. Acute hemolytic transfusion reaction
• AHTR is hemolysis of donor red cells, within 24 hours of transfusion, by preformed alloantibodies
in the recipient circulation
Pathophysiology of immune hemolysis
• Mechanisms – 1) Intravascular hemolysis
2) Extravascular hemolysis

46. Intravascular hemolysis

47. Extravascular hemolysis
• RBCs are removed from the circulation and destroyed by phagocytosis
• Rarely severe because complement activation usually is not complete(red cell are coated with
C3b), and cells are gradually removed and destroyed as they circulated through the liver and spleen

48. Signs and symptoms of AHTR
Mild reaction Severe reaction
Fever Hypotension
Urticaria Loin/back pain
Rash Jaundice
pruritis Pain at infection site
Respiratory distress
Dark urine
Severe tachycardia
DIC

49. Management of AHTR
• Stop transfusion & maintain venous access
• Rapid assessment of patient & requirements for basic & advanced support
• Notify transfusion service, collect transfused units & tubing and return to
Blood bank
• Reconfirm identity of blood units & patient
• Collect appropriate patient blood specimens

50. Management of AHTR
• 1. Maintain IV fluids at 3000 ml/M2/day with administration of sodium bicarbonate to
keep pH >7.0
• 2. Diuretics:
• Mannitol (20%) 100ml/ M2 given over 30-60 min, then 30 ml/M2/hr for next 12 hrs.
• Furosemide : Adults: 20-80 mg. / Infants & children: 1-2 mg/kg up to an adult dose
• 3. Dopamine, low dose: 1-5 mcg/kg/min
• 4. Replacement of coagulation factors and platelets
• 5. Heparin (controversial in severe DIC) enhances antithrombin III

51. Febrile Nonhemolytic Transfusion reaction
• Defined as a temperature rise of at least 1◦C occuring with or without chills within
24 hours of transfusion without any medical explanation
• Occur in 0.5% to 6% of all red cells transfusions and up to 30% of platelets
transfusions.
• Due to a reaction between human leukocyte antigens (HLAs) and/or leukocyte-
specific antigens on transfused lymphocytes, granulocytes, or platelets in the
donor unit and antibodies in previously alloimmunized recipients.

52. • FNHTRs especially associated with transfusion of platelets, may be caused
by the infusion of biologic response modifiers, such as cytokines.
• Usually seen with multiply transfused individuals and multiparous women

53. Management of FNHTRs
Stop transfusion to clinically assess:
• Consider acute hemolytic, and bacterial sepsis as part of differential
• Report TR to lab, send bag and samples to lab for work up
• Treat symptoms with antipyretic (acetominophen)

54. Allergic transfusion reactions
• Frequent 1 in 250
• Usually mild, self-limited
• Urticaria
• Antihistamine prevents
• Patient is allergic to something in the donor (foodstuff, medication, protein)
• If Donor is atopic, Should not be allowed to donate

55. Anaphylactic reactions
• Due to immediate hypersensitivity of the immune system
• Caused due to preformed, class-specific, recipient anti-IgA to
• infused donor proteins in patients with IgA deficiency
Symptoms
• Cough,
• bronchospasm,
• dyspnea,
• hypotension,
• syncope,
• shock

56. Management of allergic reactions
• Stop transfusion, keep IV line open with normal saline
• Injection Avil/dexa iv
• Inject epinephrine(adrenaline) s/c or IM
• Inject antihistamine
• For those rare patients with a history of an anaphylactic reaction to
blood/plasma and who have congenital IgA deficiency and have anti-IgA
antibodies, blood component depleted of plasma should be used
• For RBCs transfusion, this can be accomplished by using saline-washed or frozen-thawed
RBCs.
• If plasma is needed, it should be from a known IgA deficient donor

57. Transfusion-Related Acute Lung Injury (TRALI)
• Transfusion recipient experiences acute respiratory insufficiency and /or X-ray findings
are consistent with bilateral pulmonary edema but has no other evidence of cardiac failure
or a cause for respiratory failure.
• Defined acute lung injury (ALI) as a syndrome of:
– acute onset;
– hypoxemia
– bilateral lung infiltrates on a chest x-ray; and
– no evidence of circulatory overload.
• New ALI occurring during transfusion or within 6 hours of completion

58. Reaction between granulocyte antigens and antibodies
↓
Activation of complement, histamine-mediated events or prostaglandins
↓
Increased pulmonary capillary permeability
↓
fluids and proteins leak into alveolar space/interstitium
Other mechanism : Accumulation of reactive lipid products from donor cell
membranes during storage, resulting in activation of neutrophils and subsequent
damage to and leakage of capillary endothelium

60. Manifestation
• Transfusion-related acute lung injury (TRALI) is manifested by an acute
onset of respiratory distress, dyspnea, cyanosis, fever, and chill.
• An X-ray of chest will show bilateral pulmonary infiltrates, but no other
signs of left heart failure are seen.
• Potentially fatal hypoxia may occur and persist for 24-28 hours.

61. Treatment
• The cornerstone of therapy is effective supportive care for respiratory insufficiency.
Oxygen therapy and sometimes ventilatory assistance.
• Intravenous steroids are used empirically, but their effectiveness has not been proven.
• If TRALI is caused by patient anti-leucocyte antibodies the leucocyte-poor components
should be used.
Usually pulmonary sufficiency returns within 10 - 12 hours.
The donor who has been implicated in a case of TRALI and who possesses potent leuko-
agglutinins can trigger reactions in other patients and should be deferred from donating
blood