Blood transfusion

Leneressa Faith M. Digamo

OUTLINE
Preparation
Type
Screen
Crossmatch

Administration
Products
Dose
Indications

Complication
Acute
Chronic
Infectious

What is blood transfusion?

a process of taking blood or blood products
from one person (donor) and giving it to
another person (recipient) through an
intravenous line into one of the blood vessels

Usually done as a life saving maneuver to

replace blood products lost through severe
severe bleeding or to increase the blood
count in anemia

Blood Composition
Liquid phase
plasma

Solid phase
Cellular components
Erythrocytes
Leukocytes
Platelets

Differential Centrifugation
First Centrifugation

Closed System

Whole
Blood
Main Bag

RBCs

Satellite Bag
1

First

Platelet-rich Plasma

Satellite Bag
2

Differential Centrifugation
Second Centrifugation

RBCs

Platelet-rich
Plasma

Second

RBCs

Platelet
Concentrate

Plasma

Blood transfusion involves the use of whole

blood, red blood cells, white blood cells,
plasma, clotting factors and platelets.

Pre-transfusion testing
To ensure the blood or blood products to
be transfused are compatible with the
patients red cells and the antibodies in the
patients plasma
To exclude any blood or blood products
that may have the potential to harm the
patient

 Type
Test for ABO and Rh (D) grouping

Screen
Screening for atypical antibodies

Crossmatch
Final check of ABO compatibility

Blood Typing

2 types of ABO typing

Forward typing
performed by mixing a sample of blood with
anti-A serum and with anti-B serum
whether the blood cells stick together
(agglutinate) in the presence of either of these
sera determines the blood type

 Reverse typing
patient's serum is mixed with blood that is
known to be either type A or B to watch for
agglutination

A person's blood type is confirmed by the

agreement of these two tests.

RH

CAN ACCEPT

Positive

Positive or negative

Negative

Negative

Screening
There are many other antigens patients
may have developed antibodies to one of
these other antigens
The presence of such antibody is determined
by mixing the patients serum with red cells of
a known antigenic makeup

Crossmatching
(Compatibility testing)

Performed between the recipients serum or

plasma and the donors red cell
To detect unexpected/unidentified red cell
antibodies

Neonates (<4 mos)

Requires limited pre-transfusion testing
Determination of ABO is based on red cell
typing only (forward typing)
Serum typing is not performed
ABO antibodies present after birth are of
maternal origin

The Rh(D) type of red cell units must be

compatible with both mother and infant

Blood Products

Fresh whole blood &

whole blood
Fresh whole blood (FWB)
blood collected within 48 hours into a blood bag
with appropriate anticoagulant
provides RBC, plasma and platelets

After 48 hours it is termed whole blood (WB)

contains the red cells and plasma component of
donor blood
No functional platelets and labile coagulation
factors V and VIII

 Storage
4 for up to 35 days

Indications
should be discouraged, patients should be given
specific blood products
Massive Blood Loss/Trauma/Exchange Transfusion

Considerations
Donor and recipient must be ABO identical

RBC Concentrate
(PRBC)
Preparation
allow the blood to separate under gravity overnight
the plasma is removed

Storage
4 for up to 42 days, can be frozen

Indications
Many indications
Hemoglobin level (anemia)
Risk for inadequate oxygenation (hypoxia)

Pediatric indications

hemoglobin level of < 8 10 g/dl (hematocrit 0.25 0.30)

accompanied by tachypnea, tachycardia, recurrent apnea, poor
feeding and poor weight

hemoglobin level of < 130 g/dl

in acutely ill neonates with cardiorespiratory disease

hemoglobin <80 g/L or hematocrit <25%

in a stable neonate with clinical manifestations of anemia, namely
tachycardia, tachypnea, and poor feeding

neonates and premature infants when there is shock associated with

blood loss or sepsis, cumulative loss of 10%

 Transfusions may be
stringently to children

given

more

normal hemoglobin levels are lower in healthy

children than in adults
children do not have the underlying
multiorgan, cardiorespiratory,and vascular
diseases that develop with aging in adults

children often compensate better for RBC

loss

 Considerations
Recipient must not have antibodies to donor RBCs
(note: patients can develop antibodies over time)
Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
or 1 unit of PRBC increases the Hgb to 1gm/dl and
Hct by 3%
Usually transfuse over 2-4 hours (slower for chronic
anemia

WBC Indications 2004

PMN:

Ly:

Newborn Sepsis
Congenital/Acquired Neutropenia
PMN Dysfunction
Refractory Gram Negative Sepsis
Disseminated Varicella-Zoster

Washed red cell

Preparation
Red cells are washed with 0.9% sterile
isotonic saline
Majority of plasma proteins, antibodies and
electrolytes are removed

Indication
Confirmed deficiency of immunoglobulin A
Recurrent severe allergic-type adverse events
(fever, generalized urticarial, dyspnea)

Fresh Frozen Plasma

(FFP)
200-250 ml of plasma containing functional quantities
of all coagulation factors
Storage
FFP--12 months at 18 degrees or colder

Indications
Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion

Considerations

Plasma should be recipient RBC ABO compatible

In children, should also be Rh compatible
Account for time to thaw
Usual dose is 20 cc/kg to raise coagulation factors approx 20%

Fresh Frozen Plasma

Compatibility Important
Can Give: A plasma to A or O patient
B plasma to B or O patient
O plasma to O patient
AB plasma to anyone

Cryoprecipitate
Preparation
Thaw 1 unit FFP and recover the cold insoluble
precipitate

Storage
After collection, refrozen and stored up to 1 hour at -18

Content
Contains concentrated levels of fibrinogen, factor VIII,
Factor XIII

 Indication
Fibrinogen deficiency or dysfibrinogenemia
vonWillebrands Disease
Factor VIII or XIII deficiency

Considerations
ABO compatible preferred (but not limiting)
Usual dose is 1 unit/5-10 kg of recipient body weight

Dose

1-2 Units / 10 Kg
Expect 60-100 mg/dl rise in fibrinogen
Goal: Fibrinogen 70-100 mg/dl

Platelets
Storage
Up to 5 days at 20-24

Indications
Thrombocytopenia, Plt <15,000
Bleeding and Plt <50,000
Invasive procedure and Plt <50,000

Considerations
Contain Leukocytes and cytokines
1 unit/10 kg of body weight increases Plt count by 50,000
Donor and Recipient must be ABO identical

 ABO antigens are present on platelets

ABO compatible platelets are ideal
This is not limiting if Platelets indicated and type
specific not available

Rh antigens are not present on platelets

Note: a few RBCs in Platelet unit may sensitize the
Rh- patient

Prophylactic Platelet
TX Guidelines
Platelet Count/l
0-5,000
5-10,000
11-20,000
>20,000

Recommendation
Always
If Febrile of Minor Bleeding
If coagulopathy or minor
procedure
If Major Bleed or invasive
procedure

Transfusion
Complications

The greatest risk of a blood transfusion is

receiving a transfusion intended for another
patient.

This risk is particularly high for infants

identification bands may not be attached to their
bodies
difficulties in drawing pretransfusion compatibility
testing blood sample may lead to deviations in
usual policies
infants cannot speak to identify themselves

Acute Transfusion Reactions

Hemolytic Reactions (AHTR)

Febrile Reactions (FNHTR)
Allergic Reactions
Transfusion related acute lung injury
(TRALI)
Bacteremia

Frequency of Transfusion
Reactions
Adverse Effect

Frequency

Comments

Acute Hemolytic Rxn

1 in 25,000

Red cells only

Anaphylactic hypotensive

1 in 150,000

Including IgA

Febrile Nonhemolytic

1 in 200

Common

Allergic

1 in 1,000

Common

Delayed Hemolytic

1 in 2,500

Red cells only

RBC alloimmunization

1 in 100

Red cells only

WBC/Plt
alloimmunization

1 in 10

WBC and Plt only

Acute Hemolytic Transfusion

Reactions (AHTR)
Occurs when incompatible RBCs are transfused into a
recipient who has pre-formed antibodies (usually ABO or
Rh)
Antibodies activate the complement system, causing
intravascular hemolysis
Symptoms occur within minutes of starting the transfusion
This hemolytic reaction can occur with as little as 1-2 cc of
RBCs
Labeling error is most common problem
Can be fatal

Febrile Nonhemolytic Transfusion

Reactions (FNHTR)
Rise in patient temperature >1C (associated
with transfusion without other fever precipitating
factors)
Occurs with approx 1% of PRBC transfusions
and approx 20% of Plt transfusions
Need to evaluate for AHTR and infection

Allergic Nonhemolytic Transfusion

Reactions
Etiology
May be due to plasma proteins or blood
preservative/anticoagulant
Best characterized with IgA given to an IgA deficient patients
with anti-IgA antibodies

Presents with urticaria and wheezing

Treatment
Mild reactionsCan be continued after Diphenyhyderamine
Severe reactionsMust STOP transfusion and may require
steroids or epinephrine

PreventionPremedication (Antihistamines)

Transfusion Related Acute Lung Injury

(TRALI)
Clinical syndrome similar to ARDS
Occurs 1-6 hours after receiving plasmacontaining blood products
Caused by WBC antibodies present in
donor blood that result in pulmonary
leukostasis
Treatment is supportive
High mortality

Bacterial Contamination
More common and more severe with
platelet transfusion (platelets are stored at
room temperature)
Organisms
PlateletsGram
(+)
organisms,
Staph/Strep
RBCsYersinia, enterobacter

ie

Risk increases as blood products age (use

fresh products for immunocompromised)

Chronic Transfusion Reactions

Alloimmunization
Transfusion Associated Graft Verses Host
Disease (GVHD)
Iron Overload
Transfusion Transmitted Infection

Alloimmunization
Chronically transfused patients can develop
antibodies to WBCs as well as RBCs
Antibodies to WBCs
Can cause febrile non-hemolytic transfusion reactions
May avoid or reduce frequency and severity by
leukoreduction or pre-medication with antipyretics

Antibodies to RBCs
Can cause either acute (AHTR) or delayed hemolytic
reactions (DHTR)
Can lead to hemolytic disease of the newborn
May affect the availability of blood

Alloimmunization
Incidence:
RBC Antigens: 1:100 (1%)
HLA Antigens: 1:10 (10%)

Etiology: Immune response to foreign antigens

on RBC, WBCs, and platelets (HLA)
Presentation: Positive blood group antibody
screening test, platelet refractoriness, delayed
hemolytic reaction, hemolytic disease of the
newborn

Transfusion associated Graft

vs Host Disease (TA-GVHD)
Can develop in patients whose immune system fails to
recognize transfused WBC as foreign
Transfused WBCs (CD4 & CD8 cells) attack and kill hosts
immune system
Prevention: Irradiation of blood components for patients at
risk of developing TA-GVHD
Including:
Low infant birth weight neonates
Congenital immunodeficiencies
Certain malignancies including Hodgkins Disease
Hematopoietic stem cell transplants

HLA matched products

Blood products from blood related donors

Iron Overload
Major problem for chronically transfused patients
Sickle Cell Anemia
Thalassemia

Incidence: Invariable after >100 units of RBCs, risk

occurs after >50 units
Etiology: Multiple transfusions with obligate iron
load in transfusion-dependent patient
1 mg of iron per 1 ml of RBCs transfused (every
unit of RBC contains approximately 200mg iron)
Presentation: Diabetes, cirrhosis, cardiomyopathy

Infectious Complications
HIV
Hepatitis C
Hepatitis B
Hepatitis A
HTLV I/II
Bacteria

1 in 2,000,000
1 in 2,000,000
1 in 175,000
Rare
1 in 3,000,000
1/3,000 (for platelets)

Malaria, T Cruzi, Babesia, Yersinia,

Syphilis, Lyme, CJD, West Nile Virus

Other Rare Transfusion

Transmitted Infections
Emerging Blood-Transmitted Infections
Malaria > Risk 1:4,000,000
Chagas Disease (Trypanosoma cruzi)
The risk of transmission is 12-25% if transfused T. cruzi
seropositive blood

Babesiosis (B. microti)

risk of acquiring babesiosis from a transfused unit of
packed RBCs was estimated at about 0.17%
Parvovirus B-19
Viremic donors 0.025%

Hepatitis A: Transfusion risk is 1 in 1,000,000

 Variant Creutzfeld Jacob Disease (vCJD)

4 documented cases in UK
66 Patients know to have been transfused with blood from patient who
later died from vCJD

West Nile Virus

Dengue Virus

Other agents with viremic phase but not yet

proven to be transfusion-transmitted

Human herpes virus- 8 (HHV-8-Kaposi's sarcoma virus)

Borellia (Lyme disease)
Avian flu virus
SARS

Standard Operating
Procedures
1. Stop transfusion immediately
2. Keep vein open with 0.9 NaCl
3. Notify attending physician or ROD and
blood bank
4. Send freshly collected blood and urine
samples to blood banl
5. Send blood unit and BT set to blood bank

Thank you!