2. Background
» Human blood replacement therapy was accepted in
the late 19th century
» This was followed by introduction of blood
grouping by Landsteiner who identified the major
A,B & O groups in 1900, resulting in widespread
use of blood products in world war 1.
» Levine & Stetson in 1939 followed with the
concept of Rh grouping.
» Whole blood was considered the standard in
transfusion in late 1970s when component therapy
began to take prominence.
3. Introduction :
Blood transfusion is the process of transferring blood or
blood based products from one person into the circulatory system
of another. Safe blood transfusion should be safe to both the donor
and the recipient. Blood transfusions can be life saving in some
situations such as -
(i) Massive blood loss due to trauma or can be used to
replace blood lost during surgery.
(ii) BT may also be used to treat a severe anaemia or
(iii) Thrombocytopenia caused by a blood disease.
iv) People suffering from haemophilia or sickle cell
disease may require frequent transfusion.
4. Transfusion medicine is changing rapidly in response to new
developments. Considerable changes in approaches to
transfusion, together with the use of alternative agents, have
become apparent over the past decade. Blood transfusion can be
lifesaving but this is a scarce and costly resource. There is
increased focus on appropriate transfusion practice to ensure
quality of service provision. Blood transfusion usage remains
high, particularly in trauma, obstetrics, critical care and
cardiovascular surgery.
It is essential that our practice of blood transfusion is safe
and based on current, scientific & evidence-based
knowledge. A multidisciplinary approach that aims to
benefit patients by the reduction in inappropriate
5. For safe blood transfusions to prevent immediate reaction
the following steps must be taken.
(i) Donor selection
(ii) Recipient’s blood group is identified in respect to both
ABO and Rh systems.
(iii) Cross matching between the donor’s cell and recipient
serum and vice verse.
(iv) Blood should be screened for HBsAg, Malarial
parasites, HCV, syphilis and HIV.
6. Definitions used in transfusion therapy
» Blood product: A therapeutic substance prepared from
human blood.
» Whole blood: one unit of non separated donor blood
collected in an appropriate container containing
anticoagulant preservative solution
» Blood component: a constituent separated from whole
blood by differential centrifugation or that is obtained
directly from donor by aphaeresis
» Plasma derivative: human plasma proteins obtained
from multiple donor units of plasma under
pharmaceutical manufacturing conditions.These
products are heat or chemical treated to inactivate lipid-
enveloped viruses
7. 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.
8. PREPARATION OF BLOOD COMPONENT IS POSSIBLE DUE TO
Muliple plastic packs system
Refrigerated centrifuge.
Different sp. Gravity of cellular components:-
Red cells specific gravity 1.08 - 1.09
Platelet specific gravity 1.03 - 1.04
Plasma specific gravity 1.02 - 1.03
PRINCIPLE : Differential centrifugation
technique
9. INTERCONNECTED BAG SYSTEM
DOUBLE PACK SYSTEM: Red cell and plasma cells.
TRIPLE PACK SYSTEM: Red cell, platelet concentrate
and fresh frozen plasma.
Quad packs system:
Red cells
Platelet concentrate
Cryoprecipitate (factor VIII) and
Cryo- poor plasma.
13. Blood components
» Red cell component :
1.Packed red cells : whole blood allowed to sediment
overnight at 2-6 deg.C or spun in a refrigerated
centrifuge ;supernatant plasma separated.
» High viscosity ,so rate of infusion is slow
» Increase Hb by 1gm% {hematocrit by 3%}
2. Red cell in additive solution{red cell suspension}
: red cell+minimal residual plasma+additive solution
{SAGM-Saline,adenine,glucose, mannitol}
» Increase self life from 35 days to 42 days
14. 3.leukocyte-poor red cell:
* Prevention of HLA immunisation in patients who are likely to
receive allogenic BMT
* Prevention of febrile non haemolytic transfusion reactions in
patients receiving multiple transfusion
* Prevention of transmission of CMV
4. Washed red cells: washed with NS to remove plasma proteins,
white cells & platelets.
Used for IgA deficient patients who has developed anti-IgA
antibodies, as exposure will lead to anaphylaxis
5. Frozen red cells: cryoprotective agent {glycerol} added ; stored
upto 10 yrs.used for rare blood groups, future autologous
transfusion.
15. 6. Irradiated res cells:
Gamma irradiation used.
Prevents graft vs. Host disease
Intrauterine / premature neonate transfusions
patients with immunodeficiency
patients receiving blood from 1st degree
relative donor.
16. Platelets
1.platelet concentrate :
one unit whole blood yield 50-60ml
platelet {with little plasma}
Stored at 20-24 deg with continuous
agitation
Max period 5 days
1unit platetet transfusion increase platelet
count by abt 5000/ul
Usual adult dose:4-6 units plt concentrate
{1unit/10kg body wt}
18. PLATELETPHERESIS
What is apheresis?
In apheresis blood is withdrawn from a donor or patient in
anticoagulant solution and separated into components.
One (or more) component is retained and the remaining
constituents are returned to the individual. It can be done
manually or using automated equipment.
What is plateletpheresis?
In a plateletpheresis procedure, a portion of the donor’s
platelet and some plasma is removed with the return of the
donor’s RBCs, WBCs, and remaining plasma.
19.
20. Plasma components
1.FFP:
collected from whole blood within 6hrs
Frozen at -20deg or lower temp.
Contains all coagulation factors
Stored for 1yr{in temp below -25deg}
When required transfusion, FFP is thawed between
30-37deg & then stored in 2-6deg
Since labile coagulation factors rapidly deteriorate,
FFP should be transfused within 2hrs of thawing.
21. Indication :
Bleeding d/t decreased platelet production
Bleeding in hereditary disorder of platelet
function
Massive blood transfusion
contraindicaton:
TTP
HUS
DIC
22. 2.Cryoprecipitate
Within 6 hrs of collection
Prepared by- Rapidly freezing at -20deg or lower & thawing it
slowly at 4-6 deg
A white flocculent ppt and plasma are obtained
Mixture is centrifuged & supernatant plasma removed, leaving
behind sediment of cryoprecipitate suspended 10-20ml plasma.
The unit is then refrozen {-20deg or colder} & can be stored
for 1 yr
When needed cryoprecipitate is thawed at 30-37deg&
transfused to patients
Contain : factor 8, von willebrand factor, fibrinogen,
factor 13, &. fibronectin.
23. Plasma derivatives
1.Human albumin solutions : prepared by cold ethanol
fractionation of pooled plasma
2.factor 8 concentrate
3.Prothrombin complex concentrate {PCC} :contain factor
2,7,9,10, protein C & S
A serious risk of PCC is thrombotic complications d/t
presence of small amounts of activated coagulation factors.
4.Immunoglobulin
24. 1. Registration, consent of the donor and demographic
information.
2. Medical history
3. Limited physical examination
4. Simple laboratory tests
DONOR SELECTION
Donor screening process has four major aspects :
25. PHYSICAL EXAMINATION
(i) General Appearance
(ii) Age : 18 - 65yrs
(iii) Weight : A donor weighing 45kg can give 350ml blood
(iv) Blood pressure : SBP between 100-180mm of Hg
DBP between 50-100mm of Hg.
(v) Pulse : between 80-100 beats/min and regular.
(vi) Temperature : Not to exceed 37.5oC
(vii) Donation interval : Donation interval of a unit of blood
should be at least 12 weeks except in unusual circumstances.
(viii) Donor skin : The skin at the venipuncture site should be
free of any lesion or scar of needle puncture indicative of
addiction to narcotics or frequent blood donation.
26. Systemic examination : Clinically heart, lung, and abdomen
should be normal & liver and spleen should not be palpable.
Pregnancy and abortion :
➢Pregnant or recently delivered,
abortion.
➢Lactation
Defer 6 months
After baby weaned.
27. Seizures :
Fainting, convulsions epilepsy
The most important transmissible by transfusion are
hepatitis in its several forms.
Viral hepatitis :
* Hepatitis A Permanently defer.
* HBs Ag, Hepatitis C positive.
28. Jaundice :
In case of past history of jaundice : no deferral.
HIV infection /AIDS : Permanently defer.
Kidney disease :
Acute infection of kidney (Pyelonephiritis) 6 months deferral.
Or acute infection
Of bladder (Cystitis)
Chronic kidney disease Permanently defer.
29. Recurrent injections of vaccines :
To avoid the possibility that donor, might transmit a
living virus with which they have been vaccinated, they
should not donate blood during the following 3 weeks.
Allergic donor :
Donors who suffer from very severe allergy are
unacceptable.
30. Donors with relatively minor red cell abnormality.
(i) G-6-PD deficiency
(ii) Sickle cell trait.
(iii) Thalassemia trait.
(iv) Polycythaemia vera : It is known that red cells from such
patients survive normality in the circulation of the recipients and in
the subjects own circulation but in view of the fact that these
patients sometimes develop leukemia the blood is not as rule used
for transfusion.
Malaria : Accepted 3 months after treatment.
Syphilis : Defer for 12 months after rashes disappear.
Tuberculosis : Defer for 5 years after cessation of symptoms
and treatment.
31. Medications :
If the donor is taking some medicine it may not be safe to
donate blood.
(i) Isotretinoin -- 1 month defer
(ii) Finasteride -- 1 month defer
(iii) Cortisone -- 7 days defer
Permanently rejected :
(i) Anti-arrythmic
(ii) Anticonvulsants
(iii) Anti coagulant
(iv) Anti thyroid
(v) Cytotoxic
(vi) Digitalis
(vii) Dilantin
32. Laboratory tests :
(i) Haemoglobin should not be less then 12.5g/dl
Hb is measured by -
(i) Specific gravity method using copper sulphate of
specific gravity 1.053
(ii) Sahlis method
(iii) Cyanmethaemoglobin method
33. Blood collection
The donor should not be fasting before donation.
If the last meal was taken more than 4 hours previously, the
donor should be given something to eat and drink before
donation.
Blood flowing into the bag is mixed with anticoagulant in a
ratio of 1:7 (anticoagulant : blood).
Total collection volume is from 405‐495 mL and usually, a
volume of 450 mL blood is donated, this being approximately
12% of total blood volume or 10.5 mL/kg body weight.
34. PRECAUTIONS IN BLOOD COLLECTION
Proper donor selection and aseptic venepuncture
Uninterrupted continuous flow of blood: if any unit takes>8mins,
unsuitable for preparing platelet concentrate.
Correct proportion of blood and anticoagulant taken in primary bag.
If platelets are to be harvested,it should be kept at room
temperature(20-24C) until separation.
Platelets should be separated within 6-8hours from time of
collection of blood.
35. ❖ ABO blood groups :
A and B antigen - Agglutinogen
Two antigens- type A and type B occur on the surfaces of the
RBC in a large proportion of human beings. It is these antigens (also
called agglutinogen because they often cause blood cell agglutination)
that cause most blood transfusion reactions
Antibodies against Red cells agglutinogen are called agglutinins. Thus,
type A individuals develop anti-B antibodies, type B individual develop
anti-A antibodies, type O individual develop both, and type AB individual
develop neither
❖ In addition to the ABO system of antigens in human cells, there are
systems such as the Rh, Lewis, MNSs, Lutheran, Kell, and Kidd.
36. Rh system is the second most important in pre -transfusion
testing. The presence of D antigen confers Rh positivity, while
persons who lack D antigen are Rh negative. Two allelic antigen
pairs, E/e and C/c are also found on the Rh protein. The three Rh
genes, E/e, D and C/c are arranged in tandem on chromosome 1
and inherited as a halotype i.e. CDE or Cde.
D antigen is a potent alloantigen. About 15% of
individuals lack this antigen. Exposure of these Rh-negative
people to even small amounts of Rh + ve cells, by either
transfusion or pregnancy, can result in the production of anti-D
alloantibody.
37. ❖ In the case of Rh-negative patients, every attempt must
be made to provide Rh-negative blood components to prevent
allo-immunization to the D antigen. In an emergency Rh + ve
blood can be safely transfused to a Rh negative patient who
lacks anti-D.
Pre-transfusion testing : Of a potential recipient consists of
the “type and screen”. The forward type determines the ABO
and Rh phenotype of the recipient’s RBC by using antiserum
directed against the A, B and D antigen. The reverse type
detects isoagglutinins in the patient’s serum and should
correlate with the ABO phenotype or forward type.
38. Blood grouping can be done by -
(i) Slide method
(ii) Tube method
iii) Microplate method
39. Cross matching :
Blood selected for cross matching must be ABO
compatible and lack antigens for which the patient has
alloantibodies. Non-reactive cross-matching confirms absence
of any major incompatibility.
Cross matching is of two types -
(i) Major cross-matching - Donor’s red cells is tested with
recepient’s serum.
(ii) Minor cross matching - Recipients blood is tested
against donors serum.
40. Following are some of the organism transmitted through blood.
{i) HIV-1 & 2
(ii) Hepatitis B
(iii) Hepatitis C
(iv) Hepatitis A {rare}
(v) Human Parvo virus B19
(vi) Epstein Barr Virus
(vii) Cytomegalovirus
(viii}. Human T cell lymphotropic virus (HTLVI & HTLV2)
Bacteria :
Syphilis
Brucellosis
42. (ii) Immunochromatographic : qualitative detection of
antibodies aginst HIV-1 and HIV- 2.
(iii) PCR
(iv) Western blot.
(v) p24 assay.
HIV infection is diagnosed by :
(i) ELISA
43. Hepatitis B :
In a typical HBV infection, HbsAg becomes detectable 2 to 4 weeks
before the development of symptoms.
Test used :
(i) Elisa
(ii) Immunochromotography : Detects HbsAg.
Hepatitis C: Anti HCV screening of blood using recombinant
antigen helps to identify apparently healthy blood donor who
otherwise may transmit the disease.
44. CMV :
Since a vast majority of patients have antibodies to
CMV, so it is not practical or advisable to screen donors for
CMV infection.
45. Syphilis :
Etiological agent for syphilis is Trepenoma pallidium.
Blood and its component may transmit syphilis.
(i) VDRL
(ii) Rapid plasma reagin test.
Confirmatory tests : (i) FTABS (ii) TPI
Blood volume : Anticoagulant solutions
➢ Volume of blood should be proportionate to the volume of
anticoagulant. 14ml of CPD or CPDA - 1 solution is used for
100ml of blood.
➢ Firstly ACD solution was used then came citrate
phosphate dextrose and it maintains (2, 3 DPG) levels better.
Shelf life of CPD at 2-4oC was 21 days.
46. In 1978 citrate phosphate dextrose with adenine (CPDA -
1) preservative was developed which prolongs storage of blood /
red cells at 2- 4oC to 35 days.
Special consideration’s for use of components :
Red cells transfusion.
Red cells transfusion should be ABO and Rh (D) compatible.
Transfusion of one unit of red cells should not take longer than 4
hours.
Fresh Frozen Plasma :
Plasma transfusion should be ABO compatible. Cross
matching tests are usually not performed on plasma products.
Products that have been thawed should be infused without delay
47. to avoid bacterial proliferation. This is thawed at temperature of
37°C. If it is used as a source of labile coagulation factors, it should
be used immediately and in any case within 6 hours of thawing. If
used for a purpose other than coagulation factor replacement it
should be transfused within 24 hours after it is thawed and stored
at 1-6°C
Cryoprecipitate :
The component should be thawed at temperature of 37°C
and should be used immediately. ABO compatibility should not be
a must.
Single donor plasma :
It should be transfused within 24 hours after it is thawed &
stored at 1-6°C
48. Platelets and Leucocytes :
Platelets should be ABO-identical but in absence of
availability of ABO compatible platelets, ABO-incompatible
platelets can be used.
ERROR PREVENTION :
As the most common cause of hemolytic transfusion
reaction is a clerical error, a system of preventing such errors
should be in place.
49. Functions Blood bag additive components
Sodium chloride : provide isotonicity
Adenine: ATP for red cell viability
Glucose : nutrition
Mannitol : reduce red cell lysis
Citrate : is for calcium chelation to prevent clot
formation
Phosphate: buffer to maintain optimum pH
50. Shelf life {whole blood/red cells}
» ACD : 21 days
» CPD : 21 days
» CPDA: 35 days
» SAGM : 42 days
51.
52.
53. DETECTION, REPORTING & EVALUATION :
❖ Each blood bank should have a system for detection,
reporting and evaluation of suspected adverse reaction to
transfusion (Hemovigilance). In the event of suspected
transfusion reaction, the personnel attending the patient should
notify immediately the responsible physician and transfusion
service with necessary documentation and appropriate samples.
❖ All suspected transfusion reactions should be evaluated
promptly. The evaluation should not delay proper clinical
management of the patient.
❖ The details of all cases along with the interpretation of
evaluation should be recorded and reported to the transfusion
committee.
❖ There should be a written protocol for the investigations of
transfusion reactions.
❖ Reported cases of serious reactions should be evaluated.
