AN OUTLINE OF THE SCOPE OF SERVICES

2. Rapidly Evolving Scenerio
 Year 1901 marks the history ofTransfusion Medicine : when KARL LANDSTEINER
discovered the ABO blood groups.
 Followed by development of blood typing and cross matching .
 Worlds first blood bank - established at Chicago s Cook Country Hospital by Dr
Bernard Fantus .
 In 1940 , Rh Blood Group System discovered by Karl Lansteiner andA .Weiner .
 In 1943 , Acid Citrate Dextrose Solution developed for Red Cell Storage.

3. Rapidly Evolving Scenerio
 Till 1960 , blood was collected in glass bottles and transfused without testing for
Infectious Markers .
 Between 1960-65 , commercial plastic blood collection bags containingCPDA
Citrate Phosphate Dextrose Adenine, were introduced.

4. Rapidly Evolving Scenerio
 In 1968 , screening of blood for Hepatitis B surface antigen was introduced.
 In 1981 , after the discovery of AIDS , TRANSFUSION MEDICINE was accepted as
a separate speciality .
 In 1990 , screening of blood for Hepatitis C virus was introduced.
 The use of WHOLE BLOOD has been replaced by BLOOD COMPONENTTHERAPY
since the last decade ,whole blood been restricted to neonatal exchange
transfusions only.

5. PRESENT SCENERIO
 From blood collection centres to full fledged automated departments performing
multiple specialised roles – including active patient management with Cellular
Therapies ( includes Hematopoietic Stem cellTransplantation ) , DonorApheresis ,
PatientApheresis , Patient Plasma Exchange .

6. THREE TERMS
BLOOD BANK
TRANSFUSION MEDICINE
IMMUNOHEMATOLOGY

7. BLOOD BANK
 A well organized Blood Bank is a vital component of any health care delivery
system.
 AIM IN A BLOOD BANK IS TO ENSURE :
 Quality Systems in all areas - for efficacy of blood and blood components .
 An integrated strategy for Blood Safety - for elimination of transfusion
transmitted infections (TTI) and for provision of safe blood & blood component
supply.
 Adequacy and timely access to safe blood and blood components.

8. BLOOD BANK
 REQUIREMENT :
 Adequate and trained manpower.
 Adequate infrastructure.
 A good financial base.

9. It is all about QUALITY

10. BLOOD BANK - REGULATION
 Blood Banks in India are regulated under the provisions of
the Drugs & Cosmetics Acts and Rules of 1945 .
 AIM : To improve the standards of the Blood Banks and the Blood Transfusion
Areas.
 National AIDS Control Organization (NACO) has formulated comprehensive
standards to ensure better quality control systems on collection, storage, testing
and distribution of blood and its components.

11. BLOOD BANK - REGULATION
 http://naco.gov.in/sites/default/files/Standards%20for%20Blood%20Banks%20and%2
0Blood%20Transfusion%20Services.pdf

12. INDIAN SCENERIO
At present :
 Number of Blood Banks in India (2018) = 3108
 Blood Banks in Government Hospitals = 42%
 Blood Banks in Private Hospitals = 46%
 Voluntary NGO Blood Banks = 12%

13. DELHI
http://nbtc.naco.gov.in/assets/resources/reports/commonResource_1517228234.pdf
 72 Blood Banks in Delhi out of which 66 are functional.
 Around 60 (90.9%) of the blood banks - have blood component separation facility.
 Private sector owns 36.4% of the blood banks - followed by the public sector which
owns 33.3% of the blood banks.
 Majority of the blood banks (55; 83.3%) attached to the hospitals and the
remaining (11; 16.7%) standalone blood banks.

14. Demand & Supply

15. Demand & Supply
 According to the World Health Organization (WHO), to maintain an adequate blood supply, 1-
3% of the world's population needs to be blood donors.
 Population is yet to be motivated as blood donors…..
 About 117.4 million blood donations have collected globally in 2019 . (Number increasing
every year as also is the need) https://www.who.int/news-room/fact-sheets/detail/blood-
safety-and-availability
 WHO recommends that the blood requirement of 1% of a country’s population be used as a
ballpark estimate of its blood needs.

16. Demand & Supply
 India fell short of 1.9 million units of blood in 2016 -17 : Collection was 11.1 million units
and requirement was 13 million units. https://www.indiaspend.com/india-60-tankers-short-
of-blood-in-2016-17-as-shortage-increases-53935/
 That could have aided more than 3,20,000 heart surgeries or
49,000 organ transplants, according to the official data.

17. Demand & Supply
 This is an increase from a shortage of 1.1 million units in 2015-16

18. Blood Components
BLOOD COMPONENTS
PACKED RED BLOOD CELLS
LEUCODEPLETED PACKED RED BLOOD CELLS
PLATELET RICH PLASMA
PLATELET CONCENTRATE
GRANULOCYTE CONCENTRATE
FRESH FROZEN PLASMA
CRYOPRECIPITATE
CRYO POOR PLASMA
APHERESIS PLATELETS ,PLASMA ,RED CELLS ,GRANULOCYTES

19. TRANSFUSION MEDICINE
 APHERESIS
 Apheresis : - Greek word : - SEPARATION / TAKING AWAY
 Extracorporeal Medical Treatment ( SAFE PROCEDURES - REQUIRING NO
ANESTHESIA)
 Blood of a donor/patient is withdrawn from him/her
 separated ex-vivo into some /all of its components –
 the required component to be collected /removed is taken away
 and the remainder is returned to the patients circulation .

20. APHERESIS
1. DONOR APHERESIS :
 Generates Apheresis components for the patients for various indications :
 Includes :
 Platelets – Process called Plateletpheresis
 Plasma – Plasmapheresis
 Red Blood Cells – Erythrocytapheresis
 Granulocytes – Granulocytapheresis

21. APHERESIS
 Hematopoietic Progenitor Cells (HPCs) – Autologous /Allogenic – Stem Cell
Apheresis
 MULTICOMPONENT APHERESIS
 RBCs plus Plasma
 RBCs 2 Units
 Platelets & RBCs
 Platelets & Plasma

22. THERAPEUTIC APHERESIS
2. THERAPEUTIC APHERESIS :
 ALL TYPES AIM AT :
 Treating diseases by removing substances from the blood – those causing
symptoms of the disease .
 WHAT CAN BE REMOVED ?
 Injurious and Noxious Large Molecular weight substances
 Antibodies : Auto /Alloantibodies

23. THERAPEUTIC APHERESIS
 Antigen-Antibody Complexes
 Toxins
 Protein Bound Drugs
 Myeloma Light Chains
 Endotoxins
 Cryoglobulins

24. THERAPEUTIC APHERESIS
 Lipids : Cholesterol , Triglycerides
 Poisons : Phalloid mushroom intoxications
 Life threatening intoxications with tricyclic (amitriptyline)
antidepressants
 4-cyclic (maprotyline) antidepressant
 Drugs such as L-thyroxine, verapamil, diltiazem , carbamazepine
,
theophylline and heavy metals : mercury and vanadate
 Phospho - organic substances are not removed effectively.

25. THERAPEUTIC APHERESIS
1)Therapeutic Plasma Exchange (TPE) :
Removal of the liquid portion of blood
to remove harmful substances and replacement with a
replacement solution .
(Plasma , Normal Saline , CPP , 5 % Albumin)

26. THERAPEUTIC APHERESIS
(2)Therapeutic Red Cell Exchange :
Involves RBC exchange : Sickle Cell disease , Malarial Parasitemia , Babesiosis .
(3) LDLApheresis :
Removal of Low Density Lipoprotein in patients with familial hypercholesterolemia

27. THERAPEUTIC APHERESIS
( 4 )Therapeutic Cytapheresis : Involves specific cells.
a) Photopheresis : Collection of circulating Mononuclear Cells, exposing them to
photoactivating 8- Methoxypsoralen, and then exposure to UltravioletA light - Graft-
versus host disease ,CutaneousT-cell lymphoma and rejection in heart transplantation.
b) Leukocytapheresis : Removal of malignant white blood cells - in patients with
Leukemia, esp when very high white cell counts are causing symptoms – Chronic
lymphosarcoma ,T cell leukemia , Prolymphocytic leukemia , Sezary cell syndrome ,

28. THERAPEUTIC APHERESIS
,hairy cell leukemia – especially leukemias resistant to chemotherapeutic approaches.
c)Thrombocytapheresis : Removal of platelets in cases with symptoms from extreme
elevation in platelets - in cases with myeloproliferative disorders, essential
thrombocythemia or polycythemia vera.
d)Therapeutic Erythropheresis : Removal of Red Blood Cells eg Patients of Polycythemia
Vera and Hemochromatosis.

29. THERAPEUTIC PLASMA EXCHANGE
 Removal of blood plasma and returning the remaining blood constituents to the
patient and replacing the plasma volume with various types of replacements fluids .
 Replacement fluids include : Normal Saline 0.9% , Fresh Frozen Plasma , Cryo Poor
Plasma , Albumin 5 % .

30. THERAPEUTIC PLASMA EXCHANGE
AND DIALYSIS
Low molecular weight toxic constituents in plasma – Hemodialysis ; Many substances with
low and middle molecular weight are targeted.
Higher molecular weight substances such as immunoglobulins or immune complexes in
plasma -Therapeutic plasma exchange (TPE)/Plasmapheresis ;Target is mostly single
constituent of plasma.

31. Therapeutic Plasma Exchange -
Reference Source
 American Society for Apheresis (ASFA) has issued some guidelines for the use ofTPE.
 Guidelines drawn in 2007 and revised and updated from time to time.
 Based on a systematic review of information from clinical trials , case studies and
anecdotal reports .

32. THERAPEUTIC PLASMA EXCHANGE
: ASFA Indication Categories
 ASFA Indication Categories :
 Category 1. : Standard first line therapy
 Category 11 : Second line therapy
 Category 111 : Uncertainty of effects of treatment due to inadequate data. (Evaluation of
the use ofTPE to the pathologies in category 111 – is of special importance )
 Category IV: Negative data from controlled trials or ancedotal reports.

33. DISEASE PROCEDURE INDICATION CATEGORY
RENAL AND METABOLIC
DISEASES
Antiglomerular Basement
Membrane Disease (Good
Pastures Syndrome )
Plasma Exchange I
Rapidly progressive
glomerulonephritis
Plasma Exchange III
Hemolytic Uremic
Syndrome (Atypical)
Plasma Exchange I,II
RenalTransplantation Plasma Exchange
Antibody Mediated
Rejection
Plasma Exchange I
HLA Desensitization Plasma Exchange II

34. DISEASE PROCEDURE INDICATION CATEGORY
Recurrent Focal
Glomerulosclerosis
Plasma Exchange I
HeartTransplant Rejection Plasma Exchange III
Photopheresis II
Acute Liver Failure Plasma Exchange III
Familial
Hypercholesterolemia
SelectiveAdsorption I
Plasma Exchange II
Overdose or Poisoning Plasma Exchange II-III

35. DISEASE PROCEDURE INDICATION CATEGORY
Phytanic Acid Storage
Disease
Plasma Exchange II
Sepsis,with multiorgan
failure
Plasma Exchange III
Thyrotoxicosis Plasma Exchange III

36. DISEASE PROCEDURE INDICATION CATEGORY
AUTOIMMUNEAND
RHEUMATIC DISEASES
Cryoglobulinemia Plasma Exchange I
Autoimmune Hemolytic
Anemia (Warm )
Plasma Exchange III
Rheumatoid Arthritis ,
Refractory
Immunoadsorption II
Scleroderma ( progressive
systemic sclerosis )
Plasma Exchange III
Photopheresis IV
Systemic Lupus
Erythematosus, severe
Plasma Exchange II

37. DISEASE PROCEDURE INDICATION CATEGORY
HEMATOLOGIC DISEASES
ABO Incompatible
Hematopoietic Stem Cell
Transplant
Plasma Exchange II
ABO Incompatible Solid
OrganTransplant
Kidney Plasma Exchange II
Heart ( Infants) Plasma Exchange II
Liver Plasma Exchange III
Erythrocytosis/Polycythem
iaVera
Erythrocytapheresis III

38. DISEASE PROCEDURE INDICATION CATEGORY
Leucocytosis and
Thrombocytosis,symptoma
tic
Cytapheresis I,II
Thrombotic
Thrombocytopenic Purpura
Plasma Exchange I
Post-Transfusion Purpura Plasma Exchange III
SickleCell Disease RBC Exchange I-II
Hyperviscosity associated
with Monoclonal
Gammopathy
Plasma Exchange I
Coagulation factor
Inhibitors
Plasma Exchange IV
Immunoadsorption III

39. DISEASE PROCEDURE INDICATION CATEGORY
AplasticAnemia Plasma Exchange III
CutaneousT-cell Lymphoma Photopheresis I
Red Cell Alloimmunization in
Pregnancy ( if Intrauterine
Transfusion is not available )
Plasma Exchange II
Malaria or Babesiosis RBC Exchange I , II

40. DISEASE PROCEDURE INDICATION CATEGORY
NEUROLOGICAL DISORDERS
Acute Inflammatory
Demyelinating
Polyneuropathy (Gullian –
Barre Syndrome )
Plasma Exchange I
Chronic Inflammatory
Demyelinating
Polyradiculoneuropathy
(CIDP)
Plasma Exchange I
Lambert-Eaton Myasthenic
Syndrome
Plasma Exchange II
Multiple Sclerosis
Acute CNS Inflammatory
Disease
Plasma Exchange II
Chronic progressive Plasma Exchange III

41. DISEASE PROCEDURE INDICATION CATEGORY
Myasthenia Gravis Plasma Exchange I
Paraneoplastic Neurological
Syndromes
Plasma Exchange III
Immunoadsorption III
Paraproteinemic
polyneuropathy
Due to IgG,IgA or IgM Plasma Exchange I
Due to Multiple Myeloma Plasma Exchange III
Rasmussens encephalitis Plasma Exchange II
PANDAS Plasma Exchange I

45. IMMUNOADSORPTION
 A blood purification technique in which a specific ligand is bound to an insoluble matrix in a column or a
filter .
 Plasma is separated from anticoagulated whole blood
and then perfused through the column or filter
to selectively remove the pathogenic substance
and subsequent reinfusion of patients
own plasma as well as cellular components.

46. IMMUNOADSORPTION
Devices available in the market as of today :
 Non-selective adsorbers : Selesorb : Dextran Sulphate column.
 Semi-selective : Prosorb, Immunosorba (Staphylococcal protein A agarose column- Licensed to
treat patients with IdiopathicThrombocytopenic Purpura and Rheumatoid Arthritis .Used for
other diseases as well )
 Selective :Therasorb : ImmunoglobulinAdsorber column

47. IMMUNOADSORPTION
INDIAN EXPERIENCE
 Evaflux Column 2A: Pre and Post Solid OrganTransplant : For reduction of titer values
of the plasma antibodies.
 Evaflux Column 5A : LDLApheresis : Selectively removes LDL and has been
associated with regression of Cardiovascular disease.
 CharcoalColumn : Removal of Bile Acids
 Polymyxin B Column : Removal of Endotoxin
 CelluloseAcetate : Removal of granulocytes or monocytes

48. TRANSFUSION MEDICINE
Scope :
 All types of Apheresis
 Patient Blood Management
 Donor Hemovigilance
 Patient Hemovigilance
 Adverse Donor andAdverse PatientTransfusion Reactions

49. TRANSFUSION MEDICINE
 Global perspective on blood and blood component safety and availability
 PlateletTransfusions
 Red Cell Immunology
 White Blood Cell Related Antigens andAntibodies
 Platelet Immunology

50. TRANSFUSION MEDICINE
 Immune MediatedThrombocytopenia
 Autoimmune Hemolytic Anemia & Paroxysmal Nocturnal Hemoglobinuria (ANTIBODY
RELATED HEMOLYTIC ANEMIAS)
 Leukocyte Reduced Blood & Blood Components
 Plasma and Cryoprecipitate - their purified forms , recombinant forms, coagulation factor
concentrates , Immunoglobulins .
 Hematopoietic Growth factors

51. TRANSFUSION MEDICINE
 Hematopoietic Stem CellTransplantation
 GeneTherapy
 HLA Alleles, Antigens & Antibodies
 Tissue Banking
 Adoptive Immunotherapy
 Donor Lymphocyte Infusion

52. TRANSFUSION MEDICINE
 Tissue Engineering
 Regenerative Medicine
 Dendritic CellTherapy
 Transfusion therapy in trauma and burn patients
 Transfusion therapy in neonates and infants
 Transfusion support for oncology patients

53. TRANSFUSION MEDICINE
 PerioperativeTransfusion Needs
 Obstetric transfusion practice
 Hemolytic disease of foetus and new born
 Therapeutic Phlebotomies
 Autologous blood Units
 Etc

54. IMMUNOHEMATOLOGY
SCOPE :
 ABO & Rh Blood Grouping
 AntenatalAntibodyTiter in D pos and D neg pregnant females
 Cross Matching of Patients Blood /BloodComponents & Donor Units
 Antibody screen – Done on all patient and donor blood samples
 Antibody Identification – Done onAntibody ScreenTest positive blood samples

55. IMMUNOHEMATOLOGY
 AntibodyTiter – For Pre and PostTransplant Solid OrganTransplant patients , In
pregnant females, for quality control of antiseras etc
 Platelet antibody and cross match
 Direct CoombsTest
 Indirect CoombsTest
 Extended Red Cell Phenotyping

56. IMMUNOHEMATOLOGY
 Resolution of Blood Group Discrepancies
 Transfusion Reaction workup
 Serology in Auto Immune Hemolytic Anemia
 AdsorptionTest – Auto andAllo antibody adsorption
 ElutionTest
 HLATyping & Cross Match – Before deciding forTransplant – SolidOrgan &
Hematopoietic Stem Cell

57. REGISTRATION/RECEPTION COUNTER
AND AREA

58. REGISTRATION/RECEPTION
COUNTER

59. PREDONATION SCREENING AREA

60. PRE DONATION COUNSCELLING
ROOM

61. DOCTORS ROOM

62. DONOR PHLEBOTOMY ROOM

63. APHERESIS ROOM

64. POST DONATION ROOM

65. IMMUNOHEMATOLOGY ROOM

66. Transfusion Transmitted Infection
Testing Room

67. COMPONENT AND STORAGE ROOM

68. COMPONENT AND STORAGE ROOM

69. COMPONENT AND STORAGE ROOM

70. ISSUE COUNTER

71. ISSUE COUNTER

72. WASHING & AUTOCLAVE ROOM

73. NEAR FUTURE PLANS
1) NATTested Blood & Blood Components
2) Setting the HLA AntigenTesting and Crossmatch Lab ( RT –PCR )
3) Provision for IRRADIATED BLOOD
4) Hematopoietic Stem CellTransplantation

74. National Health Portal & e-raktkosh