Blood Component Therapy
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Transcript of Blood Component Therapy
BLOOD
AND
BLOOD COMPONENT THERAPY
DR R K BISHNOI
BLOOD TRANSFUSION: HISTORY
Pope Innocent VIII
FIRST HISTORICAL ATTEMPT Of blood transfusion was in 1492. Pope Innocent VIII sank into a coma.
The blood of three boys was infused into the dying pontiff (through the mouth).
The boys were ten years old, and had been promised a ducat(kind of gold coin) each.
However, not only did the pope die, but so did the
three children.
HISTORY
China, 1000 BC The soul was contained in the blood.
Egyptians bathed in blood for their health.
Pliny and Celsus describe Romans drinking the blood of fallen gladiators to gain strength and vitality and to cure epilepsy.
Taurobolium, the practice of bathing in blood as it cascaded from a sacrificial bull, was practiced by the Romans.
RICHARD LOWER
1665, THE FIRST AUTHENTIC BLOOD TRANSFUSION (ANIMAL TO ANIMAL).
HE KEPT EXSANGUINATED DOGS ALIVE BY CONNECTING THE CAROTID ARTERY→JUGULAR VEIN OF THE RECIPIENT DOG WITH A QUILL.
•1665 conducted by Richard Lower, an Oxford physician started as dog-to-dog experiments and proceeded to animal-to-human over the next two years.
•Lower (1665)
FIRST BLOOD TRANSFUSION
Animal to Human Transfusion
Early lamb blood transfusion
WHAT IS NEW SCENARIO Transfusion practice has come a long way
from animal to human transfusion to today’s practice where we have artificial blood coming out of shelf .
Though it is expensive but at present we can select the component desired by patient according to his illness.
FOR BETTER MANAGEMENT WE SHOULD STRICTLY MAINTAIN
Proper selection of donor.
Screening of donor.
Compatibility testing.
Rational use of blood component therapy.
Transfusion and monitoring
DONOR SELECTION Criteria for donation: a healthy person with
Age:>18 yrs <60 yrs.
weight:>48kg but for
whole blood for component preparation >60kg
Hb>12.5 gm/dl
WHO CAN NOT DONATEo The person is unhealthy and thus cannot tolerate
the hemodynamic stress. Hematocrit value < 34 A blood bank or a camp organized by a blood bank is
not available
Suffering from any of the following:HepatitisB,C, HIV/AIDS, syphilis, Malaria.(MALARIA- the blood is not to be taken for six
months.)
WHO CAN NOT DONATEH/O of Jaundice during the past one year.
H/O major surgery in past 6 months.
Patient is currently suffering from a malignant disease, active TB. or epilepsy.
Women when pregnant or lactating.
Professional donors.
WHY VOLUNTARY DONATION?
Only half of the requirements of blood in India is generated by voluntary donation (30 Lac
units are donated against the 60 Lac unit requirement).
As per the Supreme Court ruling, since January 01, 1998 blood shall be accepted only from
voluntary donors. No blood bank can utilize professional (paid)
donors for collection of blood.
Indian Journal for the Practising Doctor
• Banning the professional donors in
blood donation has good impact
though resulting in "scarcity of blood" and
encouraging grey areas in marketing in private Blood Banks
NO REPLACEMENT REQUIRED FOR
Thalessemic Pts.
HIV positive pts.
Destitute pts. like shishugrah.
Hemophilic pts.
HEALTH EDUCATION ASPECTS OF BLOOD DONATION:
Human blood has no natural or synthetic substitute, so it has to be donated by other human beings.
A healthy adult can donate blood every 3-4 months. Every male has a surplus of 27ml /Kg and
every female 16ml /Kg in excess of the normal requirements.
Thus every person can donate @ 8ml/kg body weight. (8x45=360ml) at one sitting
every 3 months.
HEALTH EDUCATION ASPECTS OF BLOOD DONATION:
Blood donation- no discomfort or weakness during or after donation.
Replacement starts immediately after donation, and is complete within 12 weeks.
No chances of acquiring infection from donating blood as the entire procedure is sterile.
Voluntarily donated blood is healthy for recipients.
Professional donors are themselves unhealthy.
PRACTICE POINT:
If weight of the person is 60 kg, his total blood volume (80x60) will equal 4800 ml.
A 20% volume loss (960 ml), can be
tolerated and needs only plasma expanders.
However, pts with 30% volume loss (1440 ml): require blood transfusion.
Indian Journal for the Practising Doctor
SENDING THE REQUISITION FORM AND BLOOD SAMPLE OF PATIENT
Correct identification of the pt. Sample into the type of sample tube required by the
blood bank. Label the sample tube clearly and accurately
at the pt’s bedside the moment sample is being taken.
Labeling includes:patient’s name.Hospital registration no.Patient’s ward.Date.Signature of person taking sample.
These should match with medical records.
PRE-TRANSFUSION TESTSSerological tests:- Blood grouping-ABO
- Irregular antibody screening - type and cross-match.
o Transfusion transmitted disease tests: HIV
HBV HCV VDRL MP NAT
WHAT IS NAT?
Nucleic Acid Amplification Test is highly sensitive test for detection of the virus.
This is done by amplification of the genetic materials by over a billion folds.
NAT is a direct test for presence of Viral Genetic material in the blood.
CLOSING THE WINDOW ON VIRAL INFECTION
Detection of HIV-1
Detection of HCV
Detection of HBV
11 days 22 days
23 days 98 days
34 days 56 days
BLOOD TYPING AND SCREENING
To ensure that a person who needs a transfusion will receive compatible blood with his or her own; and
That clinically significant antibodies are identified if present.
OBJECTIVES OF B.T & COMPONENT THERAPY
Restoration of blood volumeEnhance the O2 carrying capacity of bloodMaintain Homeostasis – Platelet– Coagulation Factors– Fresh blood– FFP or Appropriate component
BLOOD
Blood is a vital and life saving fluid.
Can neither be manufactured in factories, nor substituted with blood of any other creature.
But Direct transfusion of infected blood
can lead to transmission of various diseases like hepatitis, syphilis, malaria and HIV.
SAFE BLOOD
Blood that is free of transmissible diseases,
Compatible with the recipient.
Stored optimally.
BEFORE TRANSFUSION WE MUST DETERMINE WHAT FOR ANY PROCEDURE
Whether required
How much required
Actual component required
Time of duration of transfusion
Components
Blood-cells products
-whole blood -packed red blood cells -leukocyte-poor (reduced) red cells-washed red blood cells-random-donor platelets concentrates
BLOOD PRODUCTS(1)
•Single-donor platelets concentrates.
•Irradiated blood products (red blood cells and platelets
concentrates)
•Leukocyte (granulocyte) concentrates
BLOOD PRODUCTS(1)
BLOOD PRODUCTS(2)
Plasma products • fresh-frozen plasma (FFP)• cryoprecipitate• factor concentrates (VIII,
IX) • albumin• immune globulins
CELLULAR -PRBC -PLATELETS -GRANULOCYTES
PLASMA -FFP -CRYOPRECIPITATE -FRACTIONETED COMP (FACTOR VIII AND IX)
UNMODIFIED COMPONENTS
MODIFIED PRODUCTS
•IRRADIATED -PRBC
-PLATELETS-GRANULOCYTES
•LEUCOCYTE DEPLETED -PRBC-PLATELETS
•SALINE WASHED -PRBC-PLATELETS
WHICH COMPONENTSFrom one unit of whole blood one can make•PRBC•Platelet pack(random donor)•Fresh plasma•Granulocyte pack•Fresh plasma →frozen at -30°C→FFP•Pooled plasma→ components Cryoprecipitate Albumin Gamma globulins Anti-D globulins Plasma proteins
STORAGE AND SHELF LIFEPRODUCT VOLUME INDICATIONS/
STORAGE
Red Blood Cells (RBC)
SALINE WASHEDPRBC
250 mls red cells100 ml SAGM~ CPD
02 transport
Hct. 75 ± 5%1-6 oC ~ 42 days24hrs once packed.
24 hrs
Platelets SDP(single donor,apheresis)
Buffy coat derived (4 donors, 1 plasma)
200-300 ml(NO ALIQUOTES)
300x109platelets/unit
Thrombocytopenia/Dysfunctional Platelets
20-22oC x 5 days
Constant agitator.
WHOLE BLOOD 450+63 MLS(>60KG)350+49 MLS
BLOOD LOSS1-4˚C35-42 DAYS
PRODUCT VOLUME INDICATIONSTORAGE
Fresh Plasma
(FP) ↓ FFP
100 - 150 ml/unit
100-120 ml/unit in SMS Hosp
1-6°C,35-42days.Hypoproteinemia.
All coagulation factors-20oC x 12 months
Cryoprecipitate
NOT AVAILABLE IN SMS HOSPITAL
10-15ml/unit VWF 80 I.U.VIIIc :80-120 I.U.Fibrinogen > 150 mgXIII-30°C ,1 yr
Albumin
Granulocyte pack(available)
Variable
50 ml/unit
Volume expansion
Room temp
24 hrs.
Solution Purpose Whole blood or Red cell
Storage Period
Additive Concentrations( per 100 ml )
Performances
CPD Anticoagulant and storage of
Blood
21 days Sodium Citrate (dihydrate)....2.63g Citric Acid (monohydrate)...0.299g
Dextrose (monohydrate).......2.55g
Monobasic Sodium Biphosphate (monohydrate).0.222g
Prevents coagulant of blood as Citrate ion chelates CalciumNutrition source for red cell
Adjusts pH
CPDA 1 Anticoagulant and storage of Blood
35 days Sodium Citrate (dihydrate).....2.63g Citric Acid (monohydrate)....0.299g
Dextrose (monohydrate).........2.9g
Monobasic Sodium Biphosphate (monohydrate).0.222gAdenine...........................0.0275g
Prevents coagulant of blood as Citrate ion chelates Calcium
Nutrition source for red cell
Adjusts pH
Supports to maintain ATP level in red cells
SAGM Red cell Preservation
42 days Dextrose (monohydrate)......0.900gSodium Chloride...................0.877g
Adenine...........................0.0169g
D-Mannitol.........................0.525g
Nutrition source for red cellAdjusts osmotic pressure
Supports to maintain ATP level in red cellsSupports integrity of red cell membrane (to avoid haemolysis)
Whole Blood
Contents•RBC’s•WBC’s•Platelets•Plasma•Clotting factors
WHOLE BLOOD Stored at 1-4˚C Shelf life of 35-42 days. First 4-6 hrs -100% of all the components.
Changes with time Platelets fall to less than 1% by 4-48hrs. Labile clotting factors V and VIII also disappear in same
time.• other clotting factors II,VII,IX,X thereafter.• K+ level ↑,ATP level ↓• 2-3DPG and PH ↓ especially after 5-7 days of storage.
RECONSTITUTED WHOLE BLOOD
PRBC suspended in AB Rh-VE plasma used with platelets if required.
10cc/kg body weight of whole blood will raise Hct by 3-5% and Hb by 1 to 1.5 gm%.
STORAGE OF FRESH BLOOD PRODUCTS
Fresh blood products should never be stored in clinical areas.
All products should begin administration within 30 minutes of collection from
blood bank or returned to blood bank for correct monitored storage.
All Fresh blood products need to be administered within four hours of the product bag being spiked.
WHY NOT WHOLE BLOOD AND WHY COMPONENTS?
More than 6 important componentsin each Unit of whole blood.
Each component has a specialized function.
All functions are not deranged in all the patients and so
All the components are not required all the
time.
WHY NOT WHOLE BLOOD AND WHY COMPONENTS?
Blood is always in short supply.
Making components from one unit of whole blood will satisfy the needs of more than one patient from the same unit of blood.
WHY NOT WHOLE BLOOD AND WHY COMPONENTS?
Whole blood will lead to harmful effects: plasma overloadLymphocyte mediated toxicitiesAllosensitization etc.
Some components-effective as component only eg: platelets which are otherwise destroyed in
stored whole blood. Some components-better given as components
eg: clotting factors. Level can be achieved at much higher level or even
100% by giving concentrates of such factors, than by giving whole blood or even FFP.
Indications
Acute loss of whole blood.
Exchange transfusion in infants for hemolytic anemia of the newborn.
ADVANTAGE
All components.
DISADVANTAGE
Side effects due to plasma and lymphocytes as their level remains almost 100% till last date of storage.
Simply wastage of components not required.
BLOOD TRANSFUSION
Attention : Double Check: Name, Type and Cross-match
Storage Time: Citrate Phosphate Dextrose
Acidic Citrate Dextrose
21D, 35D
Pre-heat
Observation during / after Transfusion :
BLOOD WARMERS Consider warming red blood cells in the following
circumstances: -Patient's receiving massive transfusion -The hypothermic patient requiring transfusion -Exchange transfusion.
Beigler blood warmers must only be used. Blood should NEVER be warmed via a microwave,
immersion in water or by placing it on heat generating machinery.
Blood Component Preparation“A little goes a long way”
RED CELL TRANSFUSIONS: INDICATIONS AND TRIGGERS
RED BLOOD CELLS - DESCRIPTION:
Whole blood is collected into an anticoagulant then centrifuged to separate the red cells from the plasma.
The plasma is then expressed from the whole blood bag and the remaining red blood cells (RBC) are filtered.
85% of the original RBC volume will remain after filtration.
A typical unit has a volume of 240-340 mL and a hematocrit of 80%.
Plastic Blood Bags and Component Separation
PACKED RED BLOOD CELLS (PRBC)
PRBC contains packed red cells in 22-50% of original plasma.
Has nearly 100%of polymorphonuclear cells and lymphocytes but has less than 10% platelets and clotting factors.
Ideal Hct for PRBC is 70-75%. It should not be too tightly packed.
For newborns while doing exchange transfusion,Hct can be adjusted to 50-55% using additional FFP or albumin.
Indian journal of practical pediatrics
ADVANTAGE Low volume-no circulatory overload.
Less plasma –so less citrate related toxicity.
DISADVANTAGE More viscous-flow with difficulty through pediatric IV lines. Shelf life is 24 hrs, once packed. Significant amount of plasma and leukocytes so Toxicity
related to them:Allergic reactionsNHFTRAllosensitizationGVHD
A SINGLE UNIT of blood is rarely, if at all, is of any benefit to the recipient and carries all the risks associated with blood transfusion.
INDICATIONS:PRBC
Commonest indication:-chronic transfusion dependent anemia:
Thalessemias, Sickle cell disease, Congenital dyserythropoietic anemia, Diamond Blackfan syndrome, Fanconi’s anemia, Aplastic anemia, Chronic renal failure, Cancer pts, Sideroblastic anemia etc.
INDICATIONS
Episodic transfusions for acute hemolysis G6PD deficiency, Malaria, Autoimmune hemolytic anemia, Rarely, if at all, used in nutritional anemia
-severe anemia with impending cardiac failure.
Has associated cardio-respiratory disease. Before surgery.
Indian journal of practical pediatrics
Most oftenly misused as Top-ups in pts with nutritional anemia or before surgery to keep Hb>10gm%
It is counterproductive as it can lead to immunosupression of recipient anddelay in healing.
INDICATIONS IN NEWBORNS
Any cause of bleeding.
Iatrogenic blood loss especially-sick pre-terms
Anemia of prematurity:when baby has poor sucking, apneic spells, poor weight gain, and Hb<7gm%.
Very sick neonates usually have associated sepsis, acidosis, DIC, bleeding, and anemia and will need support with PRBC, platelets and FFP.
•INDICATION FOR TRANSFUSION IN ANEMIC PATIENTS
• Decision to transfuse based on clinical condition rather than a given level of hemoglobin.
• chronic stable anemia - probably unjustifiable if the hemoglobin level is above 7g per 100ml
•Symptomatic anemia(dizziness,weakness, shortness of breath), underlying cardiac, pulmonary, or vascular disease.
CHILDREN AND ADOLESCENTSACUTE LOSS OF >25% CIRCULATING BLOOD VOLUME
HB<8GM/DL IN PERIOPERATIVE PERIOD
HB<13 GM/DL AND SEVERE CARDIOPULMONARY DISEASE
HB<8GM/DL AND SYMPTOMATIC CHRONIC ANEMIA.
HB <8GM/DL AND MARROW FAILURE.
GUIDELINES FOR PAEDIATRIC RED CELL TRANSFUSION(NELSON,S TEXT BOOK)
INFANTS WITHIN FIRST 4 MONTHS OF LIFE
Hb<13g/dl and severe pulmonary disease. -ventilation
Hb<10g/dl and moderate pulmonary disease. high flow oxygen(CPAP)
Hb <13g/dl and severe cardiac disease. (Cyanosis, CCF)
Hb<10 g/dl and major surgery.
Hb<8 g/dl and symptomatic anemia
IRON DEFICIENCY ANEMIA
Rapid hematologic response with iron therapy.
Transfusion indicated only when
anemia is very severe Hb<4gm (nelson)
WITH CHRONIC ANEMIA, Children compensate well and may be asymptomatic
despite low haemoglobin levels. Treated successfully with oral iron alone, even at
haemoglobin levels of <5 g/dl. Factors other than haemoglobin concentration
to be considered in the decision to transfuse RBCs (1)Patient's symptoms, signs, and functional capacities; (2) Presence of cardio-respiratory, vascular, and central
nervous system disease; (3)Cause and anticipated course of the anemia; and
(4) alternative therapies, such as recombinant humanerythropoietin (EPO) therapy, which is known to reduce the need for RBC transfusions and to
improve the overall condition of children.
HEALTHY PREMATURE INFANTS
Physiologic anaemia- no therapy.
Ensure diet of the infant- essential nutrients for normal haematopoiesis, especially folic acid and iron.
Premature infants feeding well and growing normally rarely need transfusion unless iatrogenic blood loss has been significant.
• Healthy premature infants-Hb< 6.5 g/dl.(nelson)
FRESH V/S STORED RBCS
The traditional use of relatively fresh RBCs(<7days of storage)has been halted in
many centers in favour of diminishing donor exposure by using a single unit of RBCs to obtain aliquots for transfusing each infant throughout its permitted duration of storage (currently 42 days).
Neonatologists who insist on transfusing only fresh RBCs generally are fearful of the rise in
the plasma potassium (K') level that occurs in RBC units during extended storage.
After 42 days of storage,plasma K* levels are approximately 50 mEq/L (0.05 mEq/ml) a value that at lst glance, seems alarmingly high.
However, the actual dose of K* transfused in the extracellular fluid is tiny.
THALLASSEMIA PTS A transfusion program generally requires
monthly transfusions, with the pre-transfusion haemoglobin level >9.5 and<10.5 g/dl.
In patients with cardiac disease, higher pre-transfusion haemoglobin levels may be beneficial.
PRECAUTIONS
Pts with chronic transfusion dependent anemia need SPECIAL PRECAUTIONS:
Detailed blood grouping should be done before first blood transfusion-minor blood group incompatibility.
Always use coomb’s negative cross-matched blood
Best is to use washed PRBC and if affordable,WBC filtered PRBC to decrease leuko-contamination.
Meticulous record of pre and post-transfusion Hb should be kept to see for transfusions and suspect hypersplenism.
Chelation should be started once serum ferritin is more than 1000 ng/ml
PRECAUTIONS
Regular check-ups for 1.Plasma borne infections,
2.LFTs3.Serum ferritin levels
o Lastly all these pts should receive hepatitis-B vaccine before their first transfusion.
Patient Donor
A A, O B B, O AB A, B, AB, OO ORh(+) Rh(+), Rh(-) Rh(-) Rh(-)
PATIENT AND DONOR RBC SELECTION BY ABO AND RH TYPE
RED BLOOD CELLS –CONTRAINDICATIONS:
RBC : should not be used:when anemia can be corrected with
specific medications, e.g., iron, B12, folic acid, erythropoietin, etc.
for volume replacement.
WHY LEUCODEPLETION
Donor lymphocytes do not serve much purpose but can lead to major side effects.
Antibodies can develop against lymphocytes and platelets and leads to NHFTR.
Activated lymphocytes can release Cytokines like IL-2,TNF during storage, which can also cause NHFTR.
NHFTR is especially a problem for patients needing recurrent transfusions.
Lymphocytes lead to allo-sensitization and subsequent graft rejection in prospective candidates for bone-marrow transplants.
Lymphocytes bear intracellular pathogens and can transmit infections like HIV,HTLV,EBV,CMV etc.
Lymphocytes can lead to pulmonary toxicities like ARDS.
In surgical pts lymphocytes can lead to immune suppression and delay healing.
Hence all these components can lead to all the above-mentioned lymphocyte mediated toxicities.
Ideally all the transfusion should be leuco-depletedespecially in patients needing recurrent transfusions and in immuno-compromised hosts.
METHODS OF LEUCODEPLETION
1.WBC filters: • 3rd generation WBC filters are highly efficient. Efficacy is 99.5% They contain fiber mesh to which the WBC stick and
get filtered. when used during collection itself they will remove lymphocytes at source and hence prevent release of cytokines on storage.
They can also be used at the bedside while transfusing the blood.
ADVANTAGE: high efficacy Simplicity to use.
DISADVANTAGE: High cost Inability to prevent TAGVHD. Each filter costs Rs.600-700/- and is not
reusable. Ideally all transfusion should be
given using filters especially if patient needs recurrent transfusions or develops NHFTR.
2.WASHED CELLS
Washing with saline or blood processor not only removes WBC but also plasma.• Efficacy of WBC removal is 90% and that of plasma is
99%.• Hence it not only will reduce NHFTR, allosensitization
toxicities related to WBC but will also reduce allergic reactions to plasma proteins.
• Preparation is simple.DISADVANTAGE:• Not very effective in leucodepletion and cannot
prevent TAGVHD.• It needs cold centrifuge to prepare washed cells.
All red cell transfusions should be given using at least washed cells and preferably
with WBC filters in pts needing recurrent transfusions and those with NHFTR or allergic reactions.
Washed platelets from mother are given to a baby suffering from allo-immune
thrombocytopenia.
3.gamma-irradiation:• TAGVHD can be prevented only with gamma-
irradiation of blood.
DISADVANTAGE:
Need for sophisticated irradiator and chances of membrane leak of the cells irradiated and
increased K+ levels.
• Hence blood should be irradiated just before infusionOr else supernatant plasma should be removed before transfusion
Ideally all blood should be irradiated where there is risk of TAGVHD.
This includes: Transfusion in newborns especially pre term
<1200gms Intrauterine transfusion.
Pt with primary or secondary immunodeficiency.
Organ transplant recipients Transfusion given to a normal person from a first degree relative donor
4.FROZEN CELLS
RBC can be frozen at -70°C and be kept for 5-7yrs.
Once thawed should be used within 24 hrs.
Efficacy for leucodepletion is 90% and plasma depletion is 99%.
Hence it reduces toxicities related to both lymphocytes and plasma.
ADVANTAGE
Availability in emergency where one can use o-ve frozen cells in AB–ve plasma.• One can collect blood from CMV negative donors.• HLA matched donor or rare blood group donor and freeze it for future use.• Lastly autologous blood collected for surgery
can be frozen and used in future, if surgery gets postponed for some reasons.
DISADVANTAGE:• Needs sophisticated instruments to prepare and
store.• Extremely costly.• It cannot prevent TAGVHD.
PLATELETS TRANSFUSIONS
PLATELETS -DESCRIPTIONS:o Prepared from a random unit of whole blood
collected in CP2D anticoagulant solution.
o Suspended in a small amount of the original plasma. o A unit contains at least 55 x 109 platelets suspended in
50-55 mL of plasma.
o Platelets may also be obtained by apheresis
TYPES OF PLATELETS
RANDOM DONOR
SINGLE DONOR
PLASMA DEPLETED PLATELETS
WASHED PLATELETS
WBC FILTERED
UV OR GAMMA IRRADIATED
PLATELETS FROM SPECIFIC DONOR:
CMV NEGATIVE OR HLA-MATCHED DONOR.
PLATELETS
Contents
Platelets
WBC’s
Plasma
PRBC
PLATELETS TRANSFUSIONS
Platelets stored at 20 to 24°C on constant agitator.
It should be transported quickly and infused rapidly over 20-30 minutes to prevent loss of platelets due to aggregation.
Should use only ABO/Rh identical compatible donor.
In emergency one can use incompatible donors though the efficacy may be less than expected.
PLATELETS- FUNCTION:
Prevent bleeding of injured blood vessel walls by forming an aggregate at the site of injury.
Participate in blood coagulation, inflammation and wound healing.
The transfusion of platelets to a patient with thrombocytopenia or bleeding should produce a rise in the platelet count and control bleeding.
PLATELETS - INDICATIONS:
o Bleeding due to severely decreased production or abnormal function of platelets.
Prophylacticaly to patients with rapidly falling or low platelet counts, less than 10 x 109/L (10,000/uL), secondary to bone marrow failure, cancer or chemotherapy.
Postoperative bleeding with platelet count less than 50 x 109/L (50,000/uL).
RANDOM DONOR PLATELETS Also called PLATELET PACK Derived from SINGLE UNIT of whole blood. Contains 5-6×10¹º in 50-60ml of plasma per pack. One unit per 10 kg will raise platelet count
by 20,000 to 30,000/cmm. ADVANTAGE
Less costly and easily available.DISADVANTAGE Expose recipient to more no of donors. One cannot use specific donor like CMV negative or
HLA matched
PLATELETS APHAERESIS
SDP: collected from a single donor via aphaeresis using cell separator and are suspended in plasma.
Also called platelet concentrate.
Volume: 150-300mL (actual volume is specified on the label)
Platelet Count: >150-500 x 109/unit.(Equivalent to 3-10 single donations.)
ADVANTAGE:o More concentrated hence more effective. Exposing recipient to only a single donor. One can use same donor again after 2-3
weeks. One can select specific donor.
DISADVANTAGE: Extremely costly. Needs sophisticated equipments. Donor has to wait for longer periods in blood
bank.
CRITERIA TO TRANSFUSE:
Usually given to those with thrombocytopenia due to decreased production than to those with increased destruction.
Platelet transfusion are given when they have significant mucosal bleeds.
Only skin bleeds do not warrant platelet transfusion, but such patients should be closely monitored for any further mucosal bleeds.
IJPP
PROPHYLACTIC PLATELET TRANSFUSION
Always controversial Child with thrombocytopenia usually do not bleed
unless the platelet count fall <50,000.Decision when to transfuse is hence based on basic disease, type of thrombocytopenia, platelet count, and presence of associated coagulation abnormalities.Well child –prophylactic transfusion with count<5,000-10,000/mm3.Sick child-transfusion given with count <10-20,000.Before surgery-<30,000 but eye surgery<50,000.Massive hemorrhage<30,000.as most of the platelets are non-functional platelets of stored blood.
GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION
CHILDREN AND ADOLESCENTS PLTs<50,000 and bleeding.
PLTs<50,000 and invasive procedure.
PLTs<20,000 and marrow failure and hemorrhagic risk factors.
PLTs<10,000 and marrow failure without hemorrhagic risk factors.
PLTs at any count but with PLT dysfunction plus bleeding or an invasive procedure.
GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION
INFANTS WITHIN FIRST 4 MO OF LIFE PLTs<100,000 and bleeding.
PLTs<50,000 and an invasive procedure.
PLTs<20,000 and clinically stable.
PLTs <100,000 and clinically unstable.
PLT at any count, but with PLT dysfunction plus bleeding or an invasive procedure.
Patient’s ABO
Group
Platelet Product Group
First Choice
Second Choice
O O
A A B
B B A
AB AB B or A
INDICATIONS :PLATELETS Platelet transfusions are given for thrombocytopenia
or for platelets dysfunctional disorders.1.DECREASED PLATELETS PRODUCTION: Bone marrow failure - Aplastic anemia -Fanconi anemia -TAR syndrome -other constitutional hypoplastic anemia. Bone marrow infiltration -leukemias and metastatic cancers. Bone marrow suppression-fulminant infections Indian journal of practical pediatrics
2.INCREASED CONSUMPTION OF PLATELETS:DICNECHUSTTPGood platelet recovery at 1 hr after transfusion,but not at 24 hrs suggesting consumption.
3.INCREASED PLATELET DESTRUCTION: Immune or non-immune . Post-transfusion purpura, auto-immune disease, ITP,
allo-immune disease of newborn. Non-immune: drugs and infections Platelet transfusion is NOT EFFECTIVE in this group as they will be immediately destroyed
after transfusion
However ,in life-threatening bleeding like intracrainial hemorrhage one may give platelet packs just to tide over crisis till splenectomy is done or IVIG is administered.
Allo-immune thrombocytopenia of newborn: Washed mother´s platelets are given to the
baby. 4.HYPERSPLENISM:Platelet transfusion may
not be effective as they will be immediately removed from circulation into enlarged spleen.
5.DILUTIONAL THROMBOCYTOPENIA:When massive amount of whole blood is used.Requires additional platelet transfusion
6.Platelet –dysfunction: various congenital and acquired platelet functional disorders
may present with significant bleeding .
o If local measures fail to control bleeding transfusion will be required.
o One should use platelets sparingly as allo-sensitization may prevent good recovery in future after a number of transfusions are given.
o One can use HLA matched platelets in such cases.
Platelet transfusion efficacy: One unit of RDP per 10 kg body wt increase
platelet count by 20,000 to 30,000/cmm.
SDP is 5-7 times more efficacious than RDP.
Efficacy of platelet transfusion depend upon:Source, type, storage, collection and administration will affect the efficacy.
Pre-transfusion count, fever, sepsis, size of liver and spleen, presence of antibodies or consumption coagulopathy and drugs taken by recipient.
CLINICALLY one can judge efficacy by looking at the cessation of bleeding.
PLATELETS – CONTRAINDICATIONS:
Bleeding is unrelated to decreased numbers or abnormal platelet function.
Consumption of platelets, in Thrombotic Thrombocytopenia Purpura (TTP) Idiopathic Thrombocytopenia Purpura (ITP), Unless the patient has a life threatening hemorrhage.
o Untreated DIC.o Thrombocytopenia associated with septicemia,untill
treatment has commenced or in cases hypersplenism.
PLATELET INCUBATORStored with constant
agitation
Recycle Life through a Plateletpheresis Donation
This is John A. Zendt, a Moody Gardens Employee donating platelets and plasma.Do you want to become an Apheresis Donor?
Recycle Life through a Platelet Aphaeresis Donation
GRANULOCYTES
Patients with severe uncontrollable infection. Congenital or acquired neutropenia. Usually reserved for neutropenic pts with
fulminent sepsis not controlled by antibiotics and antifungal ANC<300 in newborn,
<100 in infants and <500 in immunocompromised
host. It should always be used along with antibiotics
and antifungal.
GRANULOCYTES
Granulocytes in newborns -partial exchange with fresh whole blood to replace granulocytes.
DOSE:10-15ml/kg body wt. Can be repeated 12-24 hrly for 4-6 days. It is to be stored at room temperature and
to be used within 24 hrs. It has all side-effects related to plasma and
lymphocytes. Should be used ABO/Rh compatible donor.
FRESH FROZEN PLASMA - FFP DESCRIPTION: Platelet poor plasma obtained at the end of
centrifugation while making components is frozen within 4-6 hrs
at -30ºC to make FFP. It can be obtained from a whole blood donation
(approx. 250 mL) or by apheresis (approx. 500 mL).
Shelf life is one year.
FFP contains all plasma proteins including albumin, gamma-globulins and a normal concentration of fibrinogen and the labile coagulation factors VIII and V.
FRESH FROZEN PLASMA -DESCRIPTION:
One unit of FFP has 150cc-200cc of plasma and 1ml of plasma contains approx 1 unit of each clotting factor.
One can use 10-15 cc/kg body weight of FFP every 12 hrly.
Hence one cannot raise factor levels beyond a certain limit without leading to volume overload.
FRESH FROZEN PLASMA –INDICATIONS: The majority of clinical situations for which FFP
is currently used do not require FFP.Pt presenting with bleeding for the first
time where the diagnosis is uncertain as to which factor is deficient.
Massive transfusion with a demonstrated deficiency of Factor VIII and V, otherwise frozen plasma is adequate.
Exchange transfusion in neonates.
FRESH FROZEN PLASMA – INDICATIONS:
Mainly used to replace clotting factors. Where multiple factors need to be replaced
liver disease, DIC,TTPWarfarin anticoagulant overdose.Pts receiving large volume of whole blood.Antithrombin III deficiency
In reconstitution of whole blood along with PRBC or to adjust hematocrit of PRBC for exchange
transfusion in newborn.
Lastly FFP is useful to prevent and treat coagulopathy due to L-asperagenase in cancer pts.
Hemophilia ,it is better to use factor concentrate.
FRESH FROZEN PLASMA As FFP contains plasma, it can lead to
allergic reactions, anaphylaxis in IgA deficient patient and can transmit all the plasma borne infections.
Hence albumin should be used as a volume expander as it is much safer.
Similarly albumin and not FFP should be used to replace proteins or albumin.
If pt need both volume expansion as well as clotting factors like in DIC, sepsis, NEC etc. one can use FFP.
In small babies, it can lead to hemolysis if it contains high levels of antibodies against recipient’s blood group antigen
FRESH FROZEN PLASMA - CONTRAINDICATIONS:
Should not be used when coagulopathy can be corrected more
effectively with specific therapy, such as vitamin K, cryoprecipitate, or Factor VIII concentrates.
Same infectious disease risk as whole blood.
Should not be used when the blood volume can be replaced with other volume expanders such as
0.9% sodium chloride, lactated ringer’s, albumin.
CRYOPRECIPITATE (CRYO) DESCRIPTION: Cryoprecipitate is prepared by thawing fresh
frozen plasma at a temperature between 1°C and 6°C.
After centrifugation, the supernatant plasma is
removed and the insoluble cryoprecipitate is refrozen.
On average, each unit of cryoprecipitate contains 80 IU or more Factor VIII (FVIII:C) and at least 150 mg of fibrinogen in 5-15 mL of plasma.
CRYOPRECIPITATE (CRYO) INDICATIONS:
Source of fibrinogen or Factor XIII.
It may be used as a source of Factor VIII only when inactivated fractionation products or recombinant Factor VIII are not available.
Fibrinogen and fibronectin are present.
CRYOPRECIPITATE (CRYO) CONTRAINDICATIONS:Should not be used unless results of laboratory
studies indicate a specific haemostatic defect.
Specific factor concentrates are preferred.
CRYOPRECIPITATE (CRYO)
Cryoprecipitate Pooling Cryoprecipitate
Patent IV access and is ready to receive the transfusion.
Check medical orders: product type, special requirements and administration
requirements.
Checks prior to administration of the blood product:
Patient identification- Name, DOB and UR on the blood transfusion record, blood product and tag and on the patient's wrist band.
PRE-TRANSFUSION CHECKS
PRE-TRANSFUSION CHECKS• If parent or guardian or child of
appropriate developmental age,include them in the patient identification
checking product. Blood product for any signs of leakage,
clots or abnormal colour.Complete documentation:
sign, date, start and finish time.• Blood Transfusion Record and file in the
patient's medical record.
PRINCIPLES OF BLOOD COMPONENT THERAPY
• Beware of the indications, risks and benefits.
The cause of the deficiency should be identified.
Alternatives to transfusion considered.
Only the deficient component should be replaced.
The product should be as safe as possible.
Informed consent and documentation should be part of the process
SAFE ADMINISTRATION OF BLOOD
Involve following:1.accurate identification of patient.2.correct labeling of blood sample for pre-transfusion testing.3.After receipt from blood bank proper storage in the clinical area upto time transfusion is given.4.A final patient identity check to ensure the administration of the right blood to the right pt.
RISK TO THE PATIENT FROM BLOOD TRANSFUSION
With the highest levels of standards, working sophistication, best of equipments and
trained personnel there are inherent risks in blood transfusion.
Some are preventable and on some there is no control.
With the present day methods there are almost negligible technical errors.
Most of the errors are clerical and result from disregard to the standard procedures.
COMMON RISKS TO PATIENT
Blood meant for one pt transfused to another pt.
Blood pack which has been infected.
Heating or freezing of the blood.
Transfusion transmitted diseases.
Adverse reaction to the blood transfusion.
DOCUMENTATION AND MONITORING
Document vital signs 1 hr prior to administration.
Immediately after commencement.
Minimum of 15 minutes after starting.
Hourly until transfusion is completed.
20-60 minutes following completion of transfusion.
CARE OF TRANSFUSED PATIENTS
o Must be undertaken for each unit transfused.
o Monitoring- adverse effects of transfusion closely during the first 15 minutes as a minimum take.
o Record vital signs: Temperature, Pulse, Respiration and Blood Pressure Before commencement 5 minutes after commencement On completion
More frequent observations particularly in unstable/unconscious patients.
TRANSFUSION REACTIONSREACTION ACUTE
(WITHIN 24 HRS)DELAYED(onset within days or months)
IMMUNE MEDIATED Hemolytic Hemolytic
Febrile non-hemolytic alloimmunisation
Allergic Post-tr purpura
Anaphylactic TAGVHD
TR-acute lung injury Immunomodulation
NON-IMMUNE MEDIATED Bacterial contamination Infections-HBV,HCV
Circulatory overload HIV-1&2
Hyperkalemia Syphilis
Thrombophlebitis Malaria
Iron-overload
TRANSFUSION REACTIONS
Febrile Reactions
• Incidence : 2%
• Chills, Fever 39-40.C
• Headache, Sweatiness
• Nausea, Vomiting, Flushing
• 15min-1hr
TRANSFUSION REACTIONS•Febrile Reactions :
•Treatment :
Immuno-reaction : Endo-toxins : Contamination or Hemolysis :
Analyze possible reasons : Stop Transfusion : General Support :
TRANSFUSION REACTIONS•Anaphylactic reactions :
• Urticaria
• Abdominal cramps
• Dyspnoea
• Vomiting
• Diarrhea
ANAPHYLACTIC REACTIONS :
•Reason : Immuno-reaction : IgE
Hereditary Immunoglobulin : IgA
•Treatment : Administer antihistamines
Administer epinephrine, diphenhydramine, and
corticosteroids : Support airway and circulation as necessary :
TRANSFUSION REACTIONS
• Burning at the intravenous (IV) line site
• Fever, Chills, Dyspnoea
• Shock
• Cardiovascular Collapse
• Hemoglobinuria, Hemoglobinemia
• Renal Failure
• DIC
Hemolytic transfusion reactions
HEMOLYTIC TRANSFUSION REACTIONS
•Reasons : ABO incompatibility
Rh Incompatibility
Non-immune Hemolysis
Immune Hemolysis
•Treatment :
Stop Transfusion as soon as reaction is suspected
Check the name, type and cross-match
Urine Exam
Renal Protection
(Aggressive Fluid Resuscitation,
Furosemide)
DIC Monitor
COMPONENT TRANSFUSION :• Saving blood source
• Less likely carrier of transmitted diseases
• Shortage of quality blood
• Greater shelf life than whole blood
• Helping to make blood safer by filtration
• Infusing regardless of ABO type in some blood
products
give only essential/desired blood component
HAEMOVIGILANCE
Set of surveillance procedures from the collection of blood to the follow-up of recipients for any untoward effect in order to prevent them in future.
Notification of transfusion-incidents by the French health authorities became a legal obligation.
The concept was introduced in 1993 when the Blood Transfusion Safety Act in France was adopted.
HAEMOVIGILANCE
The parties (or institutions) include all blood establishments, treating
physicians, transfusion committees, and consumers (recipients).
The process of 'haemovigilance' is already operational.
•Blood Safety Programme in India was initiated in 1989-90.
• Which subsequently became an integral part of the National AIDS Control Program (NACP)
•The WHO recommends that all donated blood should be tested for HIV/AIDS with either ELISA or
RAPID /SIMPLE test. •Besides, it is mandatory to test blood for hepatitis,
syphilis, and malaria.
Blood Safety
INDIA MARCHES TOWARDS SAFER BLOOD TRANSFUSION!
Now in INDIA the blood donation by professional donors is banned.
• Voluntary blood donation is encouraged.
• Screening of blood is compared as on 1991-92 (Mar-Apr) and 1996-97.
• Donors are screened for syphilis (VDRL), HBV (HBsAg), HIV (ELISA & W Blot) and malaria (MP).
.
• In 1996-97: 8 VDRL+, 19 HBsAg+
6 HIV+. No malaria+.
INDIA MARCHES TOWARDS SAFER BLOOD TRANSFUSION!
• Recipients tested for HIV after 6 months of transfusion.
• 1991-92 : 64- VDRL+ 51- HBsAg+ 2 -HIV+. No malaria+.
India marches towards safer blood transfusion!
There is reduction in VDRL+ and HBsAg+.
But the increase in HIV positivity reflects the progression of seroconversion in the
general population.
CONCLUSION: Comparatively in 1996-97 the donor samples contain less infectivity
and less contamination.
THANKS