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Blood & Blood Products S.Laxiny Medical Student FHCS EUSL

Blood- Whole Blood Fresh Whole Blood Blood Products Cellular Components- Red Cell Concentrates Platelet Concentrates Granulocyte Concentrate Plasma Components- Fresh Frozen plasma Cryoprecipitate Cryopoor plasma Stored plasma Plasma Derivatives- Albumin Immunoglobulin Coagulation Factors

Transfusion practice in Paediatrics For transfusion purpose,there are two groups of children 1.Neonates and infants <4 months 2.Infants >4 months and children Neonates and infants <4 months- No demonstrable amount of anti-A & anti-B In infants >4 months & children- Blood grouping Antibody screening Cross matching

Blood volume Premature baby 100ml/kg Full term baby 85ml/kg Infant 72ml/kg Children 76ml/kg Adults 80ml/kg

Hemoglobin concentration in children Age Hb concentration g/dl Cord blood +16.5 Day 1 +18.0 1 month +14.0 3 months +11.0 6months-6 years +12.0 7-13 years +13.0 Amount to be transfused must br carefully calculated,

Whole Blood (WB) Whole blood=Donor blood + Anticoagulant 1 Unit-450ml Anticoagulant (CPDA-1)-63ml No functional platelets No labile coagulation factors WB is used for component preparation. Hct-45% Stored at 2-6 0 c Shelf life-35 days

Whole Blood Mandatory screening tests HBsAg Anti-HCV Anti-HIV 1 & 2 VDRL/ TPPA Malarial Parasite

Fresh Whole Blood Packed Red Cells Light spin, 22 o C(within 8 hrs) Platelet Rich Plasma Platelet Concentrate Fresh Plasma Store at 22 o C Freeze(FFP) Heavy spin,22 o C

Preparation of blood components from whole Blood

Whole Blood Indications Acute blood loss with hypovolaemia Exchange transfusion-severe anaemia at birth severe hyperbilirubinaemia Massive transfusion Cardiovascular bypass surgery

Whole Blood Risk of volume overload : Chronic anaemia Cardiac failure Dose of blood transfusion -20ml/kg Increase Hb by 1 g/dl Rate of Blood Transfusion -3ml/kg/hr Transfusion considerations -ABO compatible Cross match compatible Start transfusion slowly

Whole Blood Potential Adverse Effects Reactions-Haemolytic Febrile Allergic Anaphylactic Infectious diseases Sepsis Circulatory overload TA-GVHD TRALI

Fresh Blood Blood < 5 days Source of coagulation factors, platelets & WBC Blood <5days for Exchange transfusion in newborns-to prevent hyperkalemia & to supply red cells with adequate content of 2,3-DPG.

Blood Products Red Cell Concentrates Platelet Concentrates Granulocyte Concentrate Fresh Frozen plasma Cryoprecipitate Cryopoor plasma Stored plasma Albumin Immunoglobulin Coagulation Factors Plasma Derivatives Plasma Components Cellular Components Blood

Red Cell Concentrates Also called Packed Red Cells Platelets and plasma are removed I Unit- 200- 250ml Hct-65-75% Shelf life-35 days Stored at 2-4 0 c Preferable to transfuse immediately

Red Cell Concentrates Indications Anaemia Thalassemia Sickle cell disease

Guidelines for Paediatric red cell transfusions Anaemia Infants within first 4 months of life Hb< 13.0 g/dL and severe pulmonary disease Hb < 10.0 g/dL and moderate pulmonary disease Hb < 13.0 g/dL and severe cardiac disease Hb < 10.0 g/dL and major surgery Hb < 8.0 g/dL and symptomatic anemia Acute blood loss >10% of total blood volume.

Guidelines for Paediatric red cell transfusions Infants >4 months & children Acute loss > 25% circulating blood volume Hb < 8.0 g/dL in perioperative period Hb < 13.0 g/dL and severe cardiopulmonary disease Hb < 8.0 g/dL and marrow failure Hb < 8.0 g/dL and symptomatic chronic anemia

Red Cell Concentrates Autoimmune hemolytic anaemia RCC to prevent coronary insufficiency, congestive heart failure, cardiac decompensation or neurological impairment. Transfusion may stimulate autoantibody production complicating subsequent transfusion.

Red Cell Concentrates Thalassemia Periodic regular blood transfusions Every 3 or 4 weeks Rate 2-3 hours/unit Pre transfusion Hb level -9-10g/dl Post transfusion Hb should not rise >14g/dl

Red Cell Concentrates Thalassemia Annual blood consumption=total blood transfused over 12 months/patien’s weight in middle of the year. If blood consumption is >200ml/kg BW spleenectomy should be considered

Sickle cell disease Indications for simple top up transfusion Severe anaemia Splenic or hepatic sequestration Aplastic crisis Indications in surgery Organ transplantation Eye,major abdominal surgery Don’t raise >10g/dl=raise viscosity

Red Cell Concentrates Dose of blood transfusion -10ml/kg cardiac failure -3-5ml/kg Increase Hb by 1 g/dl Rate of Blood Transfusion -3ml/kg/hr Adverse effects :Same as Whole blood

Leucoreduced Red Blood Cells Most plasma & 70-80% WBC(buffy coat) removed &100ml of AS added. Indication Symptomatic anaemia Suitable for patients requiring repeated transfusions. Prevent febrile non haemolytic reactions.

Leucoreduced Red Blood Cells WBC : <5  10 8 /L Hct : 50–60 % Volume : 350 ml Shelf life : 42 days Stored at 2- 6 0 c

Dose of blood transfusion -10ml/kg Rate of Blood Transfusion -3ml/kg/hr Increase Hb by 1 g/dl Transfusion considerations -ABO identical Crossmatch compatible Adverse effects : Same as Whole blood except febrile reactions .

Leucodepleted Red Blood Cells Same as leucoreduced RBC But WBC <5  10 6 / L Hct : 50–60 % Volume : 350 ml Shelf life : 42 days Stored at 2- 6 0 c Indications: Symptomatic anaemia Prevent febrile non haemolytic reactions. Suitable for patients requiring repeated transfusions.

Washed Red Blood Cells RBC washed with 1-2 L Normal Saline RBC : 20% reduced Plasma 90% reduced WBC : 90% reduced WBC count: <5  10 8 /L Prevent febrile non hemolytic reactions. Washing eliminates antibodies & other plasma constituents Indications: Symptomatic anemia Transfuse within 6 hours

Washed Red Blood Cells Indications Multitransfused patients with recurrent febrile reactions Urticarial reactions Anaphylactic reactions IgA deficiency with IgA antibodies Paroxysmal nocturnul hemoglobinuria Patients with T activated cells by infections who require transfusion

ABO group selection for RBC Transfusion Recipient ABO Group Component ABO Group 1 st Choice 2 nd Choice 3 rd Choice 4thChoice A A O None None B B O None None AB AB A B O O O None None None Oh (Bombay Group) Oh None None None

Platelets Concentrate Types of Platelets Recovered platelets(Random donor platelets) Apheresis platelets(single donor platelets)

Platelets Concentrate Random donor platelets Made from a unit of whole blood. Prepared by 2 methods Platelet rich plasma Buffy coat removal I unit :50  10 9 platelets Volume: 50 ml

Platelets Concentrate Single donor platelets Made from single donor Apheresed using cell separator machine 1 unit SDP: 300  10 9 = 6 units RDP Volume of 1 unit SDP: 200-350 ml

Platelets Concentrate Stored at 20 0 c-24 0 c Shelf life: 5days Once issued should be transfused as soon as possible Uses Prophylactic Therapeutic

Platelets Concentrate Guidelines for Pediatric Platelet Transfusions INFANTS WITHIN FIRST 4 MONTHS OF LIFE PLTs < 100 × 10 9 /L and bleeding PLTs < 50 × 10 9 /L and invasive procedure PLTs < 20 × 10 9 /L and clinical stable PLTs < 100 × 10 9 /L and clinically unstable PLTs at any count, but with PLT dysfunction plus bleeding or invasive procedure

Platelets Concentrate CHILDREN AND ADOLESCENTS PLTs < 50 × 10 9 /L and bleeding PLTs < 50 × 10 9 /L and invasive procedure PLTs < 20 × 10 9 /L and marrow failure with hemorrhagic risk factors PLTs < 10 × 10 9 /L and marrow failure without hemorrhagic risk factors PLTs at any count, but with PLT dysfunction plus bleeding or invasive procedure

Platelets Concentrate Contraindications TTP(Thrombotic Thrombocytopenic Purpura) HIT(Heparin Induced Thrombocytopenia) Should be ABO compatible

ABO group selection for Platelet Transfusion Recipient ABO Component ABO 1 st Choice 2 nd Choice 3 rd Choice 4thChoice A A AB B O B B AB A O AB AB A B O O O A B AB

Granulocytes Granulocyte concentrate Buffy coat Granulocyte concentrate Prepared by apheresis 1 unit Contain 1  10 10 Granulocytes Volume: 200-300 ml 1 or more units daily

Granulocytes Buffy Coat Layer between red cells & plasma I unit: 1-2  10 9 Volume: 50 ml Stored at 22 0 c-24 0 c Shelf life -1 day Should be ABO & Rh specific Should be irradiated to prevent GVHD Dose-10 units/day Should be administered within 12 hours.

Granulocytes Indications Severe neutropenia (<0.5  10 9/ L) with severe infections Contraindications Bone marrow failure sepsis PUO

Irradiated blood products Inactivate T-Lymphocytes Prevent GVHD Shelf life-28 days Indications Bone marrow/ stem cell transplant Intrauterine transfusions Congenital immunodeficiency syndrome Premature newborn Neonatal exchange transfusion-give within 24 hours.

Blood warming Warming is not necessary for routine transfusions. Warming of blood increase red cell metabolism & bacterial growth. Electric warmer or water bath is used to warm blood Indication Exchange transfusion in neonates Presence of cold agglutinins Rapid infusion through CVP lines

Blood Donation Emblem Blood Donation Emblem

Plasma components Fresh Frozen plasma Cryoprecipitate Cryopoor plasma Stored plasma

Fresh frozen plasma Contains All coagulation factors Plasma proteins Indications Single clotting factor deficiency Multiple clotting factors deficiencies- DIC Massive transfusions, Warfarine overdose Haemorrhagic disease of neonates TTP Not recommened Plasma volume expansion

FFP DOSAGE 12-15ml/kg (1unit – 200-250ml) Must be ABO compatible Storage temperature: <-30 0 c Thawed in blood bank at 37 0 c

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

Cryoprecipitate (CRYO) I unit Contains FVIII, FXIII, vWF, Fibrinogen I unit =15 ml Stored at -30 0 c

Cryoprecipitate (CRYO) Indications Hemophilia A Von Willebrand’s disease FX111 or fibrinogen deficiency Dose Depend on desired Factor leve l ABO compatibility Rate 10-15ml/min Transfuse immediately

Cryopoor Plasma / Cryosupernatant Contains Stable clotting factors No factor 8 & fibrinogen Indication Replacment in plasma exchange for TTP

Stored plasma Anticoagulant factors containing preservative solution Contain stable clotting factors No labile coagulation factors Volume: 200-250 ml Shelf life-1 year Indication Plasma protien deficiency

ABO group selection for Plasma/FFP Transfusion Recipient ABO Component ABO 1 st Choice 2 nd Choice 3 rd Choice 4thChoice A A AB None None B B AB None None AB AB None None None O O AB A B

World Blood Donor Day-June 14th

Plasma derivatives Factor VIII Factor IX Factor VIII- vWF concentrates Factor VIII Indication- Hemophilia A Loading dose,maintenance dose Loading dose = desired factor VIII level – patient’s baseline level  Body weight(kg)/2

Plasma derivatives 2.Factor IX Indication- Hemophilia B Loading dose + maintenance dose Loading dose=desired factor IX level – patient’s baseline level  Body weight(kg)

Plasma derivatives 3.Factor VIII- vWF concentrates Indications- Type IIB & severe type III Von Willebrand’s disease Mild disease-FFP Moderate disease-cryoprecipitate

Plasma derivatives Albumin 2 preparations Human albumin solution4.5%(plasma protein fraction) Human albumin solution20%(salt poor albumin) Indications Nephrotic syndrome Liver disease with fluid overload

Plasma derivatives Immunoglobulin Normal immunoglobulin Prepared from normal plasma Indications Hypogammaglobulinaemia Infections Immune thrombocytopenic purpura Specific immunoglobulins Obtained from donors with high titres of antibodies Eg- anti-D, anti-hepatitis B& anti-varicella zoster

Adverse reactions of Blood Transfusion Classification –acute delayed Causes Incorrect blood component transfusion Error in collection Error in storage Error in administration of blood, Mistakes in compatibility testing, Laboratory errors

Acute Transfusion Reactions Acute adverse reactions- <24hrs 2 types 1.Immunologic 2.Non immuologic Immunologic Adverse reactions Haemolytic transfusion reaction Febrile non-hemolytic transfusion reaction Allergic Anaphylaxis Transfusion related acute lungs injury (TRALI)

Acute reactions Non immuologic acute reactions Marked fever with shock Atypical reaction with hypotension Congestive heart failure Air embolism Hypocalcaemia Hypothermia Hypokalemia and hyperkalemia Thrombophlebitis

Delayed adverse reaction >24hrs 2 types 1)Immunologic reactions 2)Non immuologic reactions Immunologic reactions Alloimmunization to RBC,WBC,platelets, Plasma protein&HLA Haemolytic reactions TA-GVHD Post transfusion purpura

Delayed adverse reaction Non immuologic reactions Iron overload Transfusion transmitted diseases

Acute Haemolytic transfusion reaction Etiology- ABO incompatibility Clinical features Symptoms Chills Chest pain Back pain Nausea, vomiting Flushing, sweating Pain at infusion site Abdominal discomfort Restlessness

Acute Haemolytic transfusion reaction Signs Fever with rigors Tachycardia Dyspnoea Tachypnoea Pallor Hypotension Hemoglobinuria Anuria / Oliguria Cyanosis Shock & DIC

Acute Haemolytic transfusion reaction Lab evidence DAT positive Indirect bilirubin increased Hemoglobinemia Hemoglobinuria

Acute Haemolytic transfusion reaction Management Stop transfusion immediately Maintain IV access with crystalloid Maintain BP,pulse Ventilation & oxygenation IV diuretics-mannitol IV frusemide IV bolus Send blood samples to blood bank-5ml of plain blood & 2ml of EDTA blood FBC and blood picture Urine sample for hemoglobinuria

Acute Haemolytic transfusion reaction If intravascular hemolysis is confirmed Monitor renal status Monitor coagulation status If hb is markedly reduced ,compatible red cell transfusion may be required to combat hypoxemia. Treat DIC if it occurs

Delayed Haemolytic transfusion reaction 3-7 days after the transfusion Most common in multiparous women & mulitple transfusions. Etiology- immunologic response to donor red cell antigen

Delayed Haemolytic transfusion reaction Clinical features Fever Jaundice Dark coloured urine Lab evidence Absence of anticipated Hb or HCT Indirect hyperbilirubinemia DAT positive

Delayed Haemolytic transfusion reaction Diagnosis Presence of alloantibodies in post transfusion sample Treatment Rarely necessary Observe urine output Transfuse of blood that lacks the responsible antigen. Issue medical card to these patients.

Febrile Non Haemolytic Transfusion Reaction Etiology- Antileucocyte antibodies against donor leucocytes& cytokines from donor leucocytes Clinical features 1-2 hours later Fever ,chills&rigors Flushing Tachycardia

Febrile Non Haemolytic Transfusion Reaction Management Stop transfusion Restart slowly Treat with oral paracetamol saline washed or leucoreduced cells

Transfusion tranmissible infections Viral infections Hepatitis A, B, C HTLV-1 & HTLV-2 HIV-1 & HIV-2 CMV EBV West Nile Virus Prion- eg.new variant CJD

Transfusion tranmissible infections Protozoal infections Trypanosoma cruzi (Chaga’s disease) Malaria Toxoplasmosis Leishmaniasis Use HBV vaccine,prophylactic anti malarial in regularly transfused patients

Transfusion tranmissible infections Bacterial contamination Rare condition Cause death Most frequent – Yersinia enterocolitica Causes Inappropriate storage conditios Improper blood warming Keeping blood in domestic refrigerators Delay in initiating blood transfusion Transfusion over > than 4 hours stored at room temperature-platelets Addition of any medication to blood bag.

Transfusion tranmissible infections Bacterial contamination Clnical features Fever 40 0 C Hypotension Collapse shock Abdominal cramps,nausea,vomiting DIC Hemoglobinuria Intravascular hemolysis Renal failure

Transfusion tranmissible infections Bacterial contamination Clinical features Fever 40 0 C with rigor immediately after transfusion Hypotension,collapse ,Shock Abdominal cramps,nausea,vomiting DIC,haemoglobinuria,renal failure

Transfusion tranmissible infections Bacterial contamination Management Stop transfusion Inspect blood bag for signs of bacterial overgrowth. Send sample for smear +culture Treat the infection

Transfusion associated graft versus host disease Etiology- engrafment of transfused functional lymphocytes Mortality>90-99% 10-12 day after transfusion Clinical features Jaundice & elevated liver enzyme Erythroderma Diarrhoea Pancytopenia Skin manifestation of GVHD Generalized swelling, erythroderma and bullous formation

Transfuion associated graft versus host disease Investigations Skin biopsy HLA typing Patients at risk All newborn & premature babies Leukemia All immunocompromised patients

Transfusion-Related Acute Lung Injury (TRALI) Etiology Antibodies to leucocytes or complement Within 4 hours Clinical features Marked respiratory distress Hypoxia Hypotension Fever Bilateral pulmonary infiltrates Normal CVP

Transfusion-Related Acute Lung Injury (TRALI) Bilateral patchy alveolar infiltrate in TRAL (b) Complete resolution a b

TRALI Treatment High dose steroids -methyl prednisolone 1g IV bolus Ventilator support/ Oxygenation Prevention Avoid use of plasma from multiparous females Use washed RBC Use leucocyte filters

Post transfusion purpura Etiology Antiplatelet antibodies 5-10 days after infusion Clinical features Acute severe thrombocytopenia in a multiparous female or multiply transfused person

Post transfusion purpura Self limited recovery in 21 days Treatment IV immunoglobulin 2g/kg over 2-5 days If not available-steroids or plasma exchange Prevention Use leucodepleted components

Allergic urticarial reaction Etiology Antibodies to plasma protein Clinical features Itching Urticaria Rash Flushing Wheezing

Allergic urticarial reaction Treatment Transfusion can be continued IV chlorpheniramine 10mg Prevention If there is previous allergic reaction-give prophylaxis Use saline washed red cells

Anaphylactic reactions Etiology- antibodies to IgA in transfused blood Occurs after infusion of few mls of blood in IgA deficient patient Clinical features Tachycardia Abdominal cramps Diarrhoea Loss of consciousness Hypothermia,hypotension,shock Absence of fever differentiates it from other reactions.

Anaphylactic reactions Treatment Stop transfusion Start IV crystalloids Give oxygen Give chlorpheniramine 10mg slowly IV Hydrocortisone 100-200 mg IV Salbutamol nebulizer If anaphylactic shock-give adrenaline 1:1000 solution 0.5ml IM Send sample for IgA level Use saline washed red cells

Iron overload Due to life long monthly transfusions In β thalassemia major It results Cardiac failure Cardiomyopathy Liver cirrhosis Diabetes Delayed growth & sexual maturation Hyperpigmentation of skin

Guidelines for Clinical transfusion practices Record the reason for transfusion Get the consent form signed by the patient. Select the blood product & quantity to be transfused. Fill the blood request form Send 5ml recipient’s blood sample with the form. Blood bank laboratory performs antibody screen & compatibility test. Check patient’s details with cross match report from blood bank. start administration of blood within ½ hour of issue from blood bank.

Guidelines for Clinical transfusion practices Record date & time of beginning & termination of blood transfusion. Use 23G needle to transfusion. Check for air bubbles in transfusion line. Hands should be washed. Chamber half fill. Monitor patient’s pulse,BP& temperature prior to initiation & during blood transfusion.

Guidelines for Clinical transfusion practices Observe the patient throughout transfusion. The first 30 minutes are crucial. Monitor patients condition at the end of blood transfusion. Return transfusion record form to the blood bank. Observe the patient for 1 hour. Monitor the post transfusion effects. Dispose the blood bag with other biohazard waste in the ward.

Don’ts for Blood Transfusion Don’t use blood without mandatory screening test. Don’t delay initiation of blood transfusion. Don’t warm blood without proper monitoring. Don’t transfuse 1 unit over more than 4 hours. Don’t use 1 transfusion set for >4 hours or >2 units of blood. Don’t leave patients unmonitored. Don’t add any medication to blood bags. Don’t forget to return unused blood to the blood bank for safe disposal. Don’t store platelets in a refrigerator.

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