Blood transfusion

1. BLOOD
TRANSFUSION
PRACTICES, COMPONENTS ,
INDICATIONS AND COMPLICATIONS
Dr Shahsnak Gaurav

2. HISTORY
 Blood transfusion in humans since 1600s
 1828- First successful blood transfusion
 1900- Landsteiner described ABO groups
 1916- First use of blood storage
 1939- Levine described Rh factor

3. INTRODUCTION
Blood can be life saving intervention, and without it many
surgical procedure can be impossible
 It may also lead to acute or delayed complications & carries
the risk of transfusion transmissible infection.
Safety and effectiveness of transmission depends on 2 key
factors ;
I. Supply of blood products that are safe , accessible at
reasonable cost & adequate to meet standard protocol.
II. Appropriate clinical usage of blood & blood products.

4. DONOR
PLATELETPHERESIS PLASMAPHERESIS
WB
PLATLET
COMPONENT
S
•1 donation
unit,
•Pooled unit
•Single donor
unit by
aphaeresis
RED CELL
COMPONENT
•Red cell concentrates
•Red cell suspension
•Buffy coat depleted red cell
•Leukocyte reduced red cell
PLASMA
COMPONENT
•Fresh frozen plasma
•Liquid plasma
•Freez dried plasma
•Cryoprecipitate
depleted plasma
•Viral inactivated
plasma
•Cryoprecipitate.
PLASMA
DERIVATIVES
•Albumin
•Coagulation
factors
•Immunoglobuli
n's

5. COMPONENT FRACTIONISATION

6. Blood component Shelf-life
Storage
temperature range
Whole blood (Fresh
Unrefrigerated)
24 hours 20–24 ºC
Red cells
Leukocyte Depleted 42 days with the
appropriate additives
2–6 ºC
Washed Leukocyte
Depleted
28 days if resuspended in
additive solution 2–6 ºC
Fresh frozen plasma
Cryodepleted plasma
Cryoprecipitate
12 months At –25 ºC or below
Platelets 5 days 20–24 ºC

7. ANTICOAGULANTS
C - SODIUM CITRATE- citrate binds with calcium ions in
blood , so the blood does not clot
P - PHOSPHATE - supports metabolism of the red cells during
storage to ensure they release oxygen readily at tissue level
D - DEXTROSE - maintains the red cell membrane to increase
storage life
A- ADENINE- provides energy source

8. Obtained from human donor by venesection, collected into sterile ,
disposable , plastic pack ,which contains CPDA.

9. Check points for signs of deterioration in
blood and plasma

10. Effect of storage on whole blood
Reduction in the pH.
Rise in the plasma potassium ion.
Progressive reduction of 2,3 DPG in the RBC
Loss of platelet function within 48hrs
Reduction in factor VIII to <10- 20% of normal in 48 hrs.
Advantages
simple and inexpensive
For patients with hemorrhage, whole blood supplies red cells ,
volume and stable coagulation factors.
Disadvantages

11. Indications
red cell replacement in acute blood loss with hypovolemia
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 anemia
- Incipient cardiac failure

12. ANTICOAGULANT STORAGE
TIME
ACD ACID CITRATE DEXTROSE 21 days
CPD CITRATE PHOSPHATE DEXTROSE 21 days
CPDA CPD-ADENINE 35 days
CP2D CITRATE PHOSPHATE DOUBLE
DEXTROSE 21 days

13. May also be called ‘packed red cells’, ‘concentrated red cells’ or
‘plasma-reduced blood’.
prepared by :-
sedimentation-by allowing the blood to separate under gravity
overnight in a refrigerator at a temperature +2 to+ 6
Centrifugation

14. Advantages
Simple and inexpensive to prepare.
Disadvantages
It has a high ratio of red cells to plasma ,which increases
viscosity, thereby increasing the time required for transfusion
The white cells are a cause of febrile non-hemolytic transfusion
reactions in some patients.

15. Indications
Replacement of red cells in anemic patients
Use with crystalloid replacement fluids or colloid solution
in acute blood loss
To improve transfusion flow, normal saline (50–100 ml)
may be added using a Y-pattern infusion set

16. 150–200 ml red cells with minimal residual plasma to which
approximately 110 ml additive solution has been added
Haemoglobin approximately 15 g/100 ml
Haematocrit 50–70%

17. Advantages
Lower packed cell volume, low Viscosity and hence Easier to infuse
Longer shelf life, permits the use of the separated components for other patients.
Disadvantages
Cost-expensive equipments
Indications
Replacement of red cells in anemic patients
Use with crystalloid replacement fluids
Contraindications
Red cells suspended in additive solution are not advised for exchange transfusion of
neonates.

18. BUFFY COAT DEPLETED
.This is removed by a semi automated technique using top & bottom
blood collection bags & an improved vaccumised extractor
Advantage-
Red cells are left, containing only about 10% of the white cells in red
cell concentrate
Less risk of transfusion reactions due to white cell antibody reactions
and the transmission of intracellular infection when the red cells are
transfused
The ‘buffy coat’ can be used to prepare platelet concentrate
Disadvantages
Cost
More skill and operator training is needed.

19. (Filtered) RED CELLS-
Special leukocyte filters are used to remove virtually all the white cells .
best use of filters is made at the time of transfusion to avoid any
contamination.
Advantages
reduces acute transfusion reactions , due to Reduces development of
immunity to white cells.
Filtered blood containing less than 1x106white cells per pack does not
transmit cytomegalovirus infection (CMV).
Disadvantages
Cost
More skill and operator training is needed

20. Indications
Minimizes white cell immunization in patients receiving repeated
transfusion
Reduces risk of CMV transmission
Patients who have experienced two or more previous febrile reactions
to red cell transfusion
Contraindications
does not prevent graft-vs-host disease, although it can improve: for
this purpose, blood components should be irradiated where facility is
available (radiation dose:25–30 Gy)
Alternative-Buffy coat-removed whole blood or red cell suspension is
usually effective in avoiding febrile non-hemolytic transfusion
reactions

21. Prepared by fractionation of large pools of donated human
plasma
Preparations
Albumin 5%: contains 50 mg/ml of albumin
Albumin 20%: contains 200 mg/ml of albumin
Albumin 25%: contains 250 mg/ml of albumin
Stable plasma protein solution (SPPS) and plasma
protein fraction (PPF):similar albumin content to albumin 5%

22. Indications -
Replacement fluid in therapeutic plasma exchange: use albumin 5%
Treatment of diuretic-resistant edema in hypoproteinaemic patients e.g.
nephrotic syndrome or ascites. Use albumin 20% with a diuretic
Contraindications - Not for use as i.v. nutrition as it is a very expensive and
inefficient source of essential amino acids
Administration
No compatibility requirements
No filter needed
Precautions -Administration of 20% albumin may cause acute expansion of
intravascular volume with risk of pulmonary oedema

23. Partially purified Factor VIII prepared from large pools of donor
plasma
Factor VIII ranges from 0.5–20 i.u./mg of protein. Preparations
with a higher activity are available
Unit of issue- Vials of freeze-dried protein , 250 i.u. of Factor
VIII
Infection risk- Current virus inactivated products do not
appear to transmit HIV, HTLV and hepatitis C, which have lipid
envelopes: the inactivation of non-enveloped viruses such as
hepatitis A and parvovirus is less effective

24. Storage Freeze-dried derivatives should be stored at a temperature of 2°C–6°C
Indications
Treatment of hemophilia A
Treatment of von Will brand's disease.
Administration
after reconstitute according to manufacturer’s instructions ,should be used within 2
hours
Alternatives
Cryoprecipitate, fresh frozen plasma:
Factor VIII prepared in vitro using recombinant DNA methods , does not have the
risk of transmitting pathogens derived from plasma donors.

25. Single donor unit in a volume of 50–60 ml of plasma should contain:
At least 55 x 10^9 platelets
<1.2 x 10^9 red cells
<0.12 x 10^9 leucocytes
Infection risk - Same as whole blood, but a normal adult dose involves between 4
and 6 donor exposures
Bacterial contamination affects about 1% of pooled units
Storage-
20°C–24°C (with agitation) for up to 5 days in specialized platelet packs
Longer storage increases the risk of bacterial proliferation and septicemia in the
recipient

26. Indications treatment of bleeding due to:
— Thrombocytopenia
— Platelet function defects
Prevention of bleeding due to thrombocytopenia, such as in bone marrow
failure
Contraindications
Not for prophylaxis of bleeding in surgical patients, unless known to have
significant pre-operative platelet deficiency
Not indicated in:
— Idiopathic autoimmune thrombocytopenic purpura (ITP)
— Thrombotic thrombocytopenic purpura (TTP)
— Untreated disseminated intravascular coagulation (DIC)
— Thrombocytopenia associated with septicaemia, until treatment has
commenced or in cases of hypersplenism

27. Dosage-
1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult,
4–6 single donor units containing at least 240 x 10^9 platelets should raise
the platelet count by 20–40 x 10^9/l
Administration
infused as soon as possible,(within 4 hours), because of the risk of
bacterial proliferation
Must not be refrigerated before infusion (reduces platelet function)
Complications
Febrile non-haemolytic and allergic utricarial reactions, (receiving
multiple transfusions.)

28. Pack containing the plasma separated from one whole blood
donation within 6 hours of collection and then rapidly frozen to
–25°C or colder
Contains normal plasma levels of stable clotting factors, albumin
and immunoglobulin
Factor VIII level at least 70% of normal fresh plasma level
Unit of issue
Usual volume of pack is 200–300 ml
Smaller volume packs may be available for children
Storage At –25°C or colder for up to 1 year

29. Indications
Replacement of multiple coagulation factor deficiencies, e.g.:
— Liver disease
— Warfarin anticoagulant overdose
— Depletion of coagulation factors in patients receiving large volume transfusions.
Disseminated intravascular coagulation (DIC)
Thrombotic thrombocytopenic purpura (TTP)
Dosage Initial dose of 15 ml/kg
Precautions
Acute allergic reactions are not uncommon, especially with rapid infusions
Severe life-threatening anaphylactic reactions occasionally occur
Hypovolemia alone is not an indication for use

30. Prepared from fresh frozen plasma by collecting the
precipitate formed during controlled thawing and
resuspending it in 10–20 ml plasma
Contains about half of the Factor VIII and fibrinogen in the
donated whole blood: e.g. Factor VIII: 80–100 i.u./pack;
fibrinogen: 150–300 mg/pack

31.  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)
— Factor XIII
As a source of fibrinogen in acquired coagulopathies: e.g. disseminated
intravascular coagulation (DIC)
Administration
If possible, use ABO-compatible product
No compatibility testing is needed
After thawing, infuse as soon as possible through a standard blood
administration set
Must be infused within 6 hours of thawing

32. TRANSFUSION

33. PREREQUISITES FOR TRANSFUSION
Proper identification of recipient's blood sample.
Checking the patients previous records.
ABO & RH compatible donor, who is free from blood
transmissible infection & irregular anti bodies
Cross matching
Proper labeling of donor blood before use

34. STEPS OF TRANSFUSION
• Once issued by the blood centre, the transfusion of whole blood, red
cells, platelet concentrate and thawed fresh frozen plasma should
be commenced within 30 minutes of removal from the optimal
storage conditions.
• Checking the patient’s identity and the blood bag before
transfusion.
• Suggested rate of transfusion
Transfusion rate depends on clinical circumstances and may vary
from 3‐5 mL/kg/hour to greatly increased rates for individuals in
hypovolaemic shock.

35. Blood products Start transfusion Complete transfusion
Whole blood / PRBC
Within 30 minutes of
removing from
refrigerator
≤ 4 hours
Discard unit if this period
is exceeded
Platelet concentrate Immediately Within 30 minutes
FFP As soon as possible Within 30 minutes
Cryoprecipitate As soon as possible Within 30 minutes
• Duration times for transfusion
• Monitoring the transfusion
• Documentation of transfusion

37. 1. Voluntary donors- a donor who gives blood freely without
receiving any money.
 Screened for transfusion and belongs to low risk category.
 Empanelled as regular blood donors
 respond to the appeals during emergencies.
2. Replacement / relative donor- donate blood in replacement
of blood need of a particular patient
3. Direct donor- a family friend of patient& of same blood
group is requested for his blood donation .

38. 4. Autologus blood donation- it involves collection & subsequent
reinfusion of patients own blood or products.
 Principal methods are;
I. Preoperative blood transfusion.
II. Acute normovolemic hemodilution
III. Blood salvage
Professional/commercial paid donors-who receive direct or
indirect monetary benefits for the blood they donated . They
presents major risk to the safety of the blood supply

39. 4. Autologus blood donation- it involves collection & subsequent
reinfusion of patients own blood or products.
 Principal methods are;
I. Preoperative blood transfusion.
II. Acute normovolemic hemodilution
III. Blood salvage
Professional/commercial paid donors-who receive direct or
indirect monetary benefits for the blood they donated . They
presents major risk to the safety of the blood supply

41. CATEGOR
Y
SIGNS SYMPTOMS POSSIBLE CAUSE
1: MILD — Urticaria
— Rash
Pruritus (itching) Hypersensitivity (mild)
2:MODERA
TELY
SEVERE
Flushing
 Urticaria
 Rigors
 Fever
 Restlessness
 Tachycardia
Anxiety
 Pruritus
(itching)
 Palpitations
 Mild dyspnoea
 Headache
Hypersensitivity (moderate–
severe)
 Febrile non-haemolytic
transfusion reactions:
— Antibodies to white blood
cells, platelets
— Antibodies to proteins,
including IgA
 Possible contamination with
pyrogens and/or bacteria
3:LIFE-
THREATENI
NG
Rigors
 Fever
Restlessness
Hypotension (fall
of ≥20% in
systolic BP)
Anxiety
 Chest pain
 Pain near
infusion site
Shortness of
breath
Acute intravascular haemolysis
 Bacterial contamination and
septic shock
 Fluid overload
 Anaphylaxis
 Transfusion-associated lung
ACUTE TRANSFUSION
REACTION

42. IMMEDIATE
MANAGEMENTCATEGORY 1: MILD 1 Slow the transfusion.
2 antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg).
3 If no improvement within 30 minutes or if worsen, treat as Category 2.
CATEGORY 2: MODERATELY SEVERE
1 Stop the transfusion. Replace the infusion set and keep IV line open with
normal saline.
2 Notify the blood bank
3 Send blood unit with infusion set, freshly collected urine and new blood
samples (1 clotted and 1 anticoagulated)
4 antihistamine IM and oral or rectal antipyretic
5 IV corticosteroids and bronchodilators if there are anaphylactoid features
6 urine 24 hours for evidence of haemolysis
7 If improvement, restart transfusion slowly
8 If no improvement within 15 minutes, treat as Category 3.

43. CATEGORY 3: LIFE-THREATENING
1 Stop.
2 normal saline (initially 20–30 ml/kg) to maintain systolic BP. If hypotensive, give over 5
minutes and
elevate patient’s legs.
3 Maintain airway and give high flow oxygen by mask.
4 adrenaline 0.01 mg/kg IM.
5.IV corticosteroids and bronchodilators if there are anaphylactoid features).
6 diuretic
7 Notify blood bank
8 Send blood unit with infusion set, fresh urine sample and new blood
9 Check a fresh urine sample for haemoglobinuria
conti…

44. 10. 24-hour urine collection and Maintain fluid balance.
11. Assess for bleeding from puncture sites or wounds. If there is clinical or
laboratory evidence of DIC ,give platelets (adult: 5–6 units) and either
cryoprecipitate (adult: 12 units) or fresh frozen plasma (adult:3 units).
12.Re-assess. If hypotensive:Give further saline 20–30 ml/kg over 5 minutes
Give inotrope, if available.
13. If urine output falling or laboratory evidence of acute renal failure (rising
K+, urea, creatinine): Maintain fluid balance accurately
Give further frusemide
Consider dopamine infusion, if available
Seek expert help: the patient may need renal dialysis.
14. If bacteraemia start broadspectrum

45. DELAYED COMPLICATIONS OF TRANSFUSION:
TRANSFUSION-TRANSMITTED INFECTIONS
HIV-1 and HIV-2
HTLV-I and HTLV-II
Hepatitis B and C
Syphilis (Treponema pallidum)
Chagas disease (Trypanosoma cruzi)
Malaria
Cytomegalovirus (CMV
Other rare transfusion-transmissible infections include:
Human parvovirus B19
Brucellosis
Epstein-Barr virus
Toxoplasmosis
Infectious mononucleosis
Lymes disease.

46. COMPLICATION PRESENTATION TREATMENT
Delayed haemolytic
reactions
5–10 days posttransfusion:
• Fever
• Anaemia
• Jaundice
• Usually no treatment
• If hypotension and oliguria,
treat as
acute intravascular
Haemolysis
Post-transfusion
purpura
5–10 days posttransfusion:
• Increased bleeding
tendency
• Thrombocytopenia
•High dose steroids
• High dose
i.v. immunoglobulin
• Plasma exchange
Graft-vs-host
disease
10–12 days posttransfusion:
• Fever
• Skin rash and
desquamation
• Diarrhoea
• Hepatitis
• Pancytopenia
Supportive care
No specific treatment
Iron overload Cardiac and liver failure
in transfusion-dependent
patients
Prevent with iron binding
agents: e. g.
desferrioxamine
OTHER DELAYED COMPLICATIONS

47. MASSIVE TRANSFUSION
The term ‘massive transfusion’ can be defined as the replacement of blood loss equivalent to
or greater than the patient’s total blood volume with stored blood in less than 24 hours (70
ml/kg in adults, 80–90 ml/kg in children or infants
Complications of massive or large volume transfusion
Acidosis
Hyperkalemia
Citrate toxicity and hypocalcaemia
Depletion of fibrinogen and coagulation factors
Depletion of platelets
Disseminated intravascular coagulation (DIC)
Hypothermia
Reduced 2,3 diphosphoglycerate (2,3 DPG)
Microaggregates

48. THANK YOU