BLOOD COMPONENT THERAPY

Soumya Ranjan ParidaBasic B.Sc. Nursing 4th yearSum Nursing College

INTRODUCTION:

Blood component therapy refers to the transfusion of the specific part of the blood which the patient needs as opposed to routine transfusion of whole blood.

Blood components are preferred because each component has specific optimal storage conditions and component therapy maximises the use of blood donations.

Why not Whole Blood and why components…???

This conserves blood resources, since one donated unit can benefit several patients.

It also provides the optimal method of transfusing patients who require large amounts of a specific blood component.

Blood components are prepared from single donations by conventional methods. Blood group compatibility between the component and the patient is important.

In contrast, blood derivatives eg. Factor concentrates are prepared from large pools of donor plasma by fractionation and purification, they have more lenient storage requirements and can be administered without regard to ABO compatibility.

The various blood components are: STANDARD: SPECIALISED:

1. Whole blood 1. Saline washed red cells 2. Packed red cells 2. Frozen red cells 3. Platelets (RDP,SDP) 3. Leucodepleted products 4. Fresh frozen plasma 4. Irradiated products 5. Cryoprecipitate. 5. Granulocytes 6. Lymphocytes 7. Lyophilized factor VIII conc Antihemophilic factor 8. Activated Prothrombin

Complex Concentrates. 9. Porcine Factor VIII conc.

Whole Blood SLOW CENTRIFUGATION

HIGH SPEED CENTRIFUGATION

RAPID FREEZING

THAWED

PRP PRBC

PLATELETS FFP

CRYOPRECIPITATE

PREPARATION OF BLOOD COMPONENTS

STORAGE OF BLOOD COMPONENTS

RBC 4 to 6 ’C PLATELETS : 22’C. FFP : -30’C CRYOPRECIPITATE :4’C

Pre Transfusion testing :

Donor blood is routinely tested for its ABO and Rh group status.

After ensuring compatibility, a cross match is performed which consists of 2 parts.:

1. Major Cross match Patient’s serum + donor red cell suspension. Look for agglutination or hemolysis. 2. Minor cross match Patient’s red cell suspension + donor’s serum Look for agglutination or hemolysis.

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Also some routine biochemical and immunological tests are performed:

Hb by CuSO4 specific gravity test. HIV HBsAg HCV Malaria. VDRL for Syphilis.

Transfusion Practices unique to Newborn:

Newborns have a different type of O2 dissociation curve and a unique response to anemia or blood loss. It responds to anemia with poor cardiovascular responses and a much delayed bone marrow response.

Newborn can poorly tolerate calcium, potassium and blood lactate loads. Hence it is better to use blood which is < 5 days old. Also old blood will have depleted stores of 2,3 –DPG which will further shift the O2 dissociation curve to left which is already to the left due to presence of high levels of HbF.

Blood products should be at room temperature before transfusion as even though the quantity is small, it can cause hypothermia and can make a newborn sick, especially a preterm; more so during exchange transfusion.

The immune system of a neonate is immature and unresponsive to antigenic stimulation in the first 4 months of life. Even when exposed to RBC antigens, newborns do not produce alloantibodies. Almost all the antibodies present in the newborn are derived transplacentally. Hence standards for pre transfusion compatibility testing can be relaxed for the first 4 months of life.

Donor is tested for ABO and Rh blood group and baby is tested for ABO and Rh for the first time.

Mother’s blood is tested for ABO and Rh as well as for antibody screen. If mother’s blood is not available, baby’s blood is tested for antibody screen. If Ab screen is negative, all subsequent transfusions can be given without cross matching provided the blood is of either O group or is ABO identical/ compatible with both child & mother & is Rh–ve / Rh compatible with the baby.

If the initial antibody screen is positive, corresponding antigen –negative blood should be given as long as the antibody persists in the neonatal circulation.

T cell immunity is also immature in newborns, especially preterms . This can lead to increased chances of TA-GVHD following use of un- irradiated blood products or use of relative as a donor.

CHOICE OF ABO GROUPRECIPIENT BLD.GROUP RBC PLATELET FFP

O GROUP O O/A/B/AB O

A GROUP A/O A/O A/AB

B GROUP B/O B/A/O B/AB

AB GROUP AB/A,B/O AB/A AB/A

WHOLE BLOOD

Whole blood should be used when a patient requires both volume replacement and increase in oxygen carrying capacity.

INDICATIONS: 1. Acute massive blood loss > 25% of estimated blood volume

or(> 17ml/kg of blood loss).2. Exchange transfusion in neonates.3. Hyperleucocytosis (WBC count > 100000/cmm) e.g. in acute leukamia.4. Cardiac Surgery.5. ECMO

INDIVIDUAL COMPONENTS:

RBCs :

RBCs are the most frequently transfused blood component, and are given to increase the oxygen carrying capacity of the blood to ultimately achieve a satisfactory tissue oxygenation.

Packed RBCs are obtained from whole blood by sedimentation or by heavy spin at 5 C to achieve a hematocrit of 70 to 80 %.

The removal of plasma decreases the amount of electrolytes and ammonia and is beneficial to patients with incipient CCF, Renal failure or hepatic failure.

Moreover the chances of allergic or anaphylactic reactions are

minimised.

Special Considerations: I. LEUCOREDUCTION: Why leucodepletion …???

Donor lymphocytes present in most of the blood components do not serve much purpose but can lead to major side effects.

Antibodies can develop against lymphocytes and platelets and lead to Non Hemolytic Febrile Transfusion Reactions (NHFTR).

Activated lymphocytes can release cytokines like IL2 and TNFa during storage which can also cause NHFTR. NHFTR is especially a problem for patients needing recurrent transfusions.

Lymphocytes lead to allosensitization, HLA antigen and

subsequent platelet refractoriness as well as graft rejection in prospective candidates for bone marrow transplants.

Lymphocytes bear intracellular pathogens and can transmit infections like HIV, HTLV, EBV and CMV.

Lymphocytes can lead to pulmonary toxicities like ARDS.

In surgical patients lymphocytes can lead to immune supression and delay healing.

In immunocompromised patients , newborns especially preterm babies and in transfusion from first degree relatives, it can lead to transfusion associated GVHD.

The dose needed for NHFTR is >5*10^6 lymphocytes & for TAGVHD > 10^7 cells/ kg body weight.One pack of PRBC has 10^9 WBC, RDP has 2.5*10^8 WBC and Granulocyte pack has 10^11 WBC.Hence all these components must be leucodepleted before transfusion so that they contain not more than 5*10^6 WBC.

The various techniques employed are:

1. Centrifugation (at 5000g for 7 mins) followed by removal of plasma and buffy coat (~80% WBCs are removed).

2. Filtration using microaggregate , cotton wool or polyester filters at the time of transfusion or just prior to issue

from blood bank.(>99% WBCs are removed).

3. Washing of RBCs in normal saline removes >85% WBCs.

4. Deglycocerolyzing frozen, thawed RBCs (98% WBCs are removed). This procedure is more expensive.

The benefits of leucoreduction are:

1. Decreased immunisation to antigens on leucocytes such as human leucocyte antigen (HLA).

2. Decreased rate of febrile transfusion reactions.

3. Minimisation of possible (and controversial)immunomodulatory effect of blood transfusion.

4. Decreased rate of CMV transmission.

IRRADIATION:

Blood products should be irradiated prior to transfusion.

Irradiation prevents transfusion associated graft versus host disease (TA-GVHD) from transfused leucocytes in cellular blood components

It is especially important for those at risk for this fatal complication. eg. Premature infants and children with certain immunodeficiencies.

Directed or designated donations have a small increase in rate of infectious disease transmission.

Also if a relative donates blood components, the blood must be irradiated since it is at increased risk for causing TA-GVHD if the donor is a first degree relative of the patient

It is thus essential to irradiate all red cell and platelet components (except FFP) for:

1. Intrauterine transfusion (IUT). 2. Exchange transfusion of red cells after IUT. 3. Top up transfusion after IUT. 4. When the donor is a first or second degree relative or a HLA

selected donor. 5. When a child has a proven or suspected immunodeficiency.

Anticoagulant - preservative solutions used:

Each unit contains approximately 250 ml of a concentrated solution of RBCs .

Composition: Hematocrit : 70%to 80% Sodium :62mg Citrate: 222mg Phosphate: 46 mg Iron: 200 to 250 mg

Three types of units are currently approved for use:

i. CPD – this contains 773 mg of Dextrose and has a 21 day shelf life.

ii. CP2D – This contains 1546 mg of dextrose and has a shelf life of 21 days.

iii CPDA1 - This contains 965 mg of dextrose and 8.2 mg of adenine and has a shelf life of 35 days. This is the most widely used of the anticoagulant-preservative solutions.

Additive solutions used: Most RBC units contain additive solutions, each unit of~350 ml, an average hematocrit of 50% to 60% and has a shelf life of 42 days. They contain Mannitol in addition to all other constituents. Proportions of all vary an different types

The changes that occur in PRBC during storage are:

The pH decreases from 7.4 to 7.55 to a pH of 6.5 to 6.6.

Potassium is released from RBCs. After 42 days of storage plasma K levels are ~ 50mEq/L.

2,3 Diphosphoglycerate (2,3- DPG) levels drop rapidly during the first two weeks of storage. This increases the affinity on hemoglobin for oxygen and decreases its efficiency in delivering oxygen to tissue.

INDICATIONS:

1.Chronic anemia due to any underlying diseases such as renal failure or malignancy and Hb <5gm%.The transfusion

requirements of each patient should be based on clinical status rather than any predetermined HCT or Hb value.

2. Thalessemia wherein the aim is to maintain the pretransfusion Hb level between 9 – 10gm%.

3. Aplastic anemia where bone marrow transplantation is not feasible transfusion is recommended when Hb is < 7gm%

4. Nutritional anemia when Hb drops to <5gm%. In severe anemia when there is an overt CHF multiple small transfusions of 3-5ml/kg over 3 hrs should be given.

5. Malignancies when Hb <7gm%. Situations where transfusions should be given in the absence of symptoms are:

(a) during radiation therapy. (b) following an intensive cycle of chemotherapy that

causes myelosupression.

GUIDELINES FOR PEDIATRIC RBC TRANSFUSIONS:

CHILDREN AND ADOLESCENTS:

Acute blood loss > 25% of circulating blood volume Hb <8gm% in the perioperative period Hb <13gm% and severe cardiopulmonary disease. Hb <8gm% and symptomatic chronic anemia. Hb <8gm% and marrow failure.

INFANTS WITHIN FIRST 4 MONTHS OF LIFE:

Hb <13gm% and severe pulmonary disease Hb <10gm% and moderate pulmonary disease Hb <13gm% and severe cardiac disease Hb <10gm% and major surgery Hb <8gm% and symptomatic anemia

DOSAGE AND ADMINISTRATION:

The usual dose is 5 to 15ml/kg at the rate of 5ml/kg/hr. This may be adjusted depending on the severity of the anemia and/ or the patients ability to tolerate increases in intravascular volume.

The higher hematocrit of CPD or CPDA RBCs (70 to80%) results in increased viscosity which may slow the transfusion rates. 50 to 100ml of isotonic NS may be used to dilute the CPD RBC to decrease the viscosity.

The lower hematocrit of AS RBC unit (50 to 60%) permits permits more rapid infusion rates.

Each 8ml/kg of RBC in children and each 3ml/ kg in infants is expected to raise the Hb by 1gm/dl and PCV by 3%

PLATELETSPLATELETS

PREPARATION AND CONTENTS:

Platelets are prepared from whole blood donations or collected by apheresis.

Each bag of 50 to 60 ml should contain at least 5* 10^10 platelets in sufficient plasma to maintain a pH of greater than 6 throughout the storage period. The anticoagulant – preservative solution used is CPD, CP2D or CPDA.

Regardless of the technique used platelets are stored for upto 5 days at 20 to 24 c with a constant gentle agitation which ensures a near normal post transfusion recovery and survival.

RDP

When a single unit of whole blood collected in triple pack plastic collection bags, PRP is separated from packed RBCs after centrifugation at 2000g. This PRP is then centrifuged at 5000g at 20’C for 2 mins , platelets separated, PPP transferred to other bag for FFP and cryoprecipitate. By this technique under optimal operating conditions 85% of platelets are removed from 1 unit of whole blood.

SDAP Apheresis refers to a technique of drawing peripheral blood,

separating it and selectively removing one or more components while returning the remainder to the donor.

GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSIONS

CHILDREN AND ADOLESCENTS:

PLT < 50000/cmm and bleeding. PLT < 50000/cmm and invasive procedure. PLT < 20000/cmm & marrow failure & hemorrhagic risk factors. PLT < 10000/cmm marrow failure without hemorrhagic risk

factors. PLT at any count but with platelet dysfunction + Bleeding or an

invasive procedure.

INFANTS WITHIN FIRST 4 MONTHS:

PLT <100000/cmm and bleeding. PLT <50000/cmm and invasive procedure. PLT <20000/cmm and clinically stable. PLT <100000/cmm and clinically unstable. PLT at any count but with platelet dysfunction + bleeding or an

invasive procedure.

DOSE: The usual dose is 10ml/ kg OR

1 unit / 10 kg body weight. ADMINISTRATION:

Before administration the platelet bag should be warmed to room temperature and should be infused over 15

to 20 min or as fast as possible.

INCREMENT:

1 unit / 10 kg of RDP will increase the platelet count by 40000 – 50000/mm3.

6 units of platelet conc. of RDP = 1 SDAP unit will increase the platelet count by 70000 to 80000/mm3.

FRESH FROZEN PLASMA

Plasma separated from single units of whole blood collected in CPD or CPDA by heavy spin at 1 – 6’c if frozen within 6 hours of collection, yields FFP.

Volume from single donation is 200 ml.

It is stored at < -30’c to preserve the activity of clotting factors. Can be stored for up to 1 yr at this temperature.

CONTENTS:

This plasma contains essentially normal levels factors II, V, VIII, IX, X and fibrinogen except factors V and VIII which often lose their activity during several months of storage.

Factor VIII levels are 0.6–0.7 units/ml (60 to 70%). Each bag of FFP contains 180 to 220 cc of plasma ie.~ 180-200 units of factor VIII and IX.

It should be thawed in a water bag at 37C and administered within 1/2 hour after thawing as the activity of factor V and VIII is rapidly lost.

INDICATIONS:

1. Replacement of coagulation factors in liver disease, def of Vit K dependant factors (II, VII, IX, X), DIC, overdoses of

anticoagulants, cardiopulmonary bypass, massive blood transfusions;

2. Specific deficiencies of factors V, VIII, XI

3. Replacement of hemostatic factors when specific concentrate preparations are not available eg. Hemophilia A and B,

deficiencies of VII, X, fibrinogen and prothrombin, von Willebrand’s disease, antithrombin III deficiency ;

4. In situations where certain plasma constituents are lacking e.g. fibronectin in septicemia,C1 esterase in hereditary angioneurotic edema, PGI2 in thrombotic thrombocytopenic purpura.

5. FFP transfusion is the only known treatment for rare inherited deficiency of factors V, XI,XII,XIII and Flecther and

Fitzgerald factors.

Dose: 10 to 20 ml/kg.

However it is useful only in management of mild bleeding. It cannot be used to control severe bleeding where large amount of factor is needed for the fear of overload as in IC bleed, acute hemarthrosis and muscular hemorrhages.

Only 10 to 15 ml/kg may be given with safety in single dose. Expected rise is of 20 to 30 % in factor VIII activity.

It should be compatible with recipients ABO type.

As FFP is harvested from single donor it holds less risk of Hepatitis, AIDS and other plasma borne infections.

SIDE EFFECTS:

1. Circulatory overload. 2. Pyrogenic reactions. 3. Allergic or anaphylactoid reactions. 4. Headache or abdominal pain 5. TRALI is more likely. 6. Acute hemolytic reactions. 7. Citrate induced hypocalcemia. 8. Development of antibodies of Factor VIII inhibitors.

CRYOPRECIPITATE

WHOLE BLOOD

FFP

Slowly Thawed 2-4’C for18 to 24 hrs

PRECIPITATEPLASMA

CRYOPRECIPITATE

Used for other purposes (contains all CF except factor

VIII & fibrinogen)

Rapid centrifugation

Refrozen & stored at temp< -30’C for 3-12

months

Cryoprecipitate contains:

i. Antihemophilic factor (factor VIII) 40-160 units/bag. ii. Riestocetin or von Willebrand factor (factor viii cofactor). iii. Factor VIII related antigen (factor VIIIR Ag). iv. Fibrinogen 200 to 250 mg/ bag. v. Factor XIII and trace elements of other factors.

The amount of factor VIIIc and fibrinogen in individual bags may vary widely.

Factor IX is not present in clinically significant amounts.

INDICATIONS:

i. Hemophilia A. ii. Von Willebrand’s disease. iii. Congenital hypo and Afibrinogenemia. iv. Cryoprecipitate shortens the abnormally long

bleeding time in platelet functional disorders, Hermansky Pudlak syndrome, Uremia, DIC and

Liver disorders.

Advantages:

1. Normal factor level can be achieved without the danger of volume overload. It contains ~ 20 times as much factor VIII per unit volume of FFP.

2. Less expensive than factor VIII concentrate. 3. Treatment of choice in von Willebrand’s disease since it

contains factor VIII c and von Willebrand factor. 4. Cryoprecipitate causes less transfusion reactions than does

plasma as the former has only a few foreign immunogenic proteins.

5. Less risk of hepatitis and AIDS as compared to factor VIII concentrate as it is prepared by a single donor. However, unlike factor VIII conc. Cryoprecipitate cannot be heat treated to eliminate contaminating viruses.

DISADVANTAGES:

1. To retain factor VIII activity for more than a few weeks, it must be kept frozen below -30’c.

2. Cryoprecipitate is extremely viscous, difficult to mix and time consuming and laborious to administer.

3. Amount of factor VIII activity varies from bag to bag.

4. Less common side effects seen are hemolytic anemia, paradoxical hemorrhages due to defective platelet function, alloimmunization to IgG determinants and the induction of circulating immune complexes. It is also causally related to increase incidence of hypertension and renal dysfunction in hemophiliacs.

GRANULOCYTES

Granulocytes concentrates can be prepared manually by harvesting the buffy coat layer from a single unit of blood or by leucopheresis.

This yields 0.5 to 0.6 x 10^9 granulocytes per unit of whole blood.

1 unit prepared by apheresis = 18-20 units of buffy coat. Granulocytes concentrates can be stored at 20-24 c for 24 hrs The product must be ABO compatible. The dose of Granulocytes recommended is 1-2 *10^9cells/kg

in 10-15 ml/kg of volume. It can be repeated 12-24 hourly for 4 to 6 days

Guidelines for transfusing neutrophils in children:

Blood neutrophils <500 /cmm and bacterial infection unresponsive to antibiotics.

Blood neutrophils <500 /cmm and yeast or fungal infections progressing or appearing during treatment with antimicrobials.

Neutrophils dysfunctions with bacterial, yeast, fungal infections

unresponsive to antimicrobials. Guidelines for transfusing neutrophils in infants

<4 months: Blood Neutrophils <3000 /cmm and fulminant sepsis during the

first week of life. Blood Neutrophils <1000 /cmm and fulminant sepsis after 1st

week of life.

FACTOR VIII CONCENTRATE

Lyophilised concentrate containing 250-1500 units of factor VIII c in a reconstituted volume of about 25 cc arte prepared from large pools of FFP from 2000-5000 paid donors.

Factor viii is purified by combining cryoprecipitation and precipitation with glycine, polyetheneglycol or ethanol and further fractionated and freeze dried.

The products are packaged in individual vials indicating the exact number of units of factor VIII activity.

ADVANTAGES:

1. Factor content per unit volume is 10-40 times greater than plasma and hence prevents volume overload.

2. They can be stored at 4’C in a home fridge and reconstituted with sterile water warmed to body temp, drawn into a syringe through a filter needle and then infused into the patient.

3. Transfusion reactions are virtually eliminated with the removal white cells and platelets.

DISADVANTAGES:

1. Since factor VIII concentrates are prepared from large lots of cold plasma, they carry the major risks of transfusion hepatitis, AIDS, toxoplasmosis and other viral infections.

2. Factor VIII concentrate are extremely expensive and are available with difficulty only in major cities. They cost

about Rs.2-4 per unit.

3. More complete purification processes result in less yield of factor VIII particularly after heat treatment.

PROTHROMBIN COMPLEX CONCENTRATES (PCC)

Lyophilized concentrate of factors II, VII, IX and X containing 500-1000 I.U. of factor IX in 25 cc are used mainly for treatment of factor IX deficiency.

They can also be used for other rare bleeding disorders as in congenital or acquired deficiencies of factor II, VII and X.

It is also used for patients with antibodies for factors VIII & IX.

ADVANTAGES.

1. Standardization. 2. Storage at 4’C. 3. Easy reconstitution with sterile water. 4. Ease of administration with syringe.

DISADVANTAGES:

1. Greater chances of Hepatitis and AIDS .

2. Increased amount of thrombogenic material leading to increased risk of thrombogenic phenomenon.

3. High risk of acute myocardial infarction and DIC.

4. Mild reactions like headache and flushing. Hence give slowly.

5. Other immediate reactions may be nausea, fever, chills, urticaria, paresthesia, hypotension and anaphylactoid reactions.

ACTIVATED PROTHROMBIN COMPLEX CONENTRATES

This product is mainly developed to bypass factor VIII or IX especially for persons with high levels of antibodies to these factors.

Limitations – High costs, high risk of transmission of hepatitis and AIDS and difficulty in lab monitoring for the effectiveness.

Trade name – AUTOPLEX, FEIBA

PORCINE FACTOR VIII CONCENTRATE

Factor VIII concentrate made from porcine plasma has low cross activity towards most antibodies.

Limitations – Severe adverse effects like anaphylaxis, thrombocytopenia and pyrogenic reactions.

To minimize these adverse effects, improved methods of fractionations are now employed to yield concentrates of very high purity with fewer or no side effects which can be further minimized by administering 100 mg of hydrocortisone.

Infusion of porcine factor VIII may be followed by rise in level of inhibiters in both human and porcine. Hence it should be monitored after treatment.

INTRAVENOUS IMMUNOGLOBINS

IVIG is a purified concentrate of solution of immunoglobulin with stabilizers such as sucrose. They can be both non diseases specific or disease specific.

Most products contain >90% Ig G with small amounts of Ig M and Ig A.

Non disease specific Ig are prepared from fractionation of plasma while specific Ig are separated from plasma from donors who possess high titres of specific antibodies.

The indications for use are:

1. Prevention and treatment of diseases such as hepatitis, rubella, Varicella Zoster, Tetanus, Measles, Rabies, etc..

2. Replacement therapy in Ig deficiency syndrome. 3. Treatment of immune disorders such as Immune

thrombocytopenic purpura, 4. Prevention of sensitization in Rh negative women by

administrating Anti D globulin. 5. Prophylaxis and treatment of neonatal sepsis. 6. Kawasaki disease.

TRANSFUSION REACTIONS:

IMMUNE MEDIATED:

1. Acute Hemolytic transfusion reactions. 2. Delayed Hemolytic and Serologic Transfusion reactions.

(DHTR) 3. Febrile Non Hemolytic transfusion reactions (FNHTR). 4. Allergic reactions like urticaria.. 5. Anaphylactic reactions. 6. Transfusion Associated Graft Versus Host Disease

(TAGVHD). 7. Transfusion Related Acute Lung Injury (TRALI). 8. Post Transfusion Purpura. 9. Alloimmunization.

NONIMMUNOGENIC REACTIONS:

1. Fluid overload. 2. Hypothermia. 3. Electrolyte toxicity 4. Iron overload. 5. Hypotensive reactions. 6. Immunomodulation.

INFECTIOUS COMPLICATIONS:

1. VIRAL INFECTIONS: HIV 1, Hepatitis B Virus, Hepatitis C Virus, Other Hepatitis Viruses like rarely HAV or HGV, CMV, HTLV Type I and Parvovirus B 19.

2. BACTERIAL INFECTIONS: Some Gm –ve bacteria e.g. Yersinia and Pseudomonas species can grow at 1 to 6’C. Platelet concentrates stored at room temperature are more likely to contain skin contaminants such as Gm +ve organisms including Coagulase negative Staphylococci.

3. OTHER INFECTIOUS AGENTS: Parasites like those causing Malaria, Babesiosis and Chagas disease. Rarely West Nile Virus, Lyme’s disease and Creutzfield Jacob disease.

REFERENCES:

Nelson. Nathan and Oski. Harrison. IAP Speciality Series on Pediatric Hematology. AABB. IAP NNF Guidelines. Cloherty. AnanthNarayan. Practical Pediatric Hematology –IAP. PUBMED

THANK YOU !!!