1. The most important liquids for mankind
Water
Petroleum
Blood
EACH IS A REASON FOR WAR !!!
And EACH HAS STRATEGIC/LOGISTIC IMPORTANCE IN WAR

2. BLOOD TRANSFUSION Prof. Dr. Sabri KEMAHLI
Professor of Pediatrics/Hematology
Alfaisal University College of Medicine

3. Learning objectives Common blood group systems
Describe the basis of blood banking
Cross matching,
Screening of blood and
Safe blood transfusion
Blood types and transfusion
Describe Blood types, Agglutination process in transfusion reactions, Blood typing, Rh blood types and Rh immune response.
Describe transplantation of tissues and organs.
Describe the process of overcoming the immune reactions in transplanted tissue.

6. in the day when blood letting was one of the principal duties of the barbering trade. The two spiral ribbons painted around the pole represented two long bandages, one twisted around the arm before bleeding (to make the vein stand out), and the other used to bind it afterwards. The patient clutched the staff firmly during the entire operation. Originally, when not in use, the pole with bandage pre-wound (so it might be ready when needed) was hung at the door as a sign. Later an imitation was painted and given a permanent place on the sidewalk outside

7. History of Blood Transfusion
Pope Innocent VIII, in Rome, had an apoplectic stroke; became weak and went into a coma. His physician advised a Blood transfusion as a therapeutic measure for the Pope's illness. Employing crude methods, the Pope did not benefit and died by the end of that year.

8. 1665 - The first Blood transfusions of record take place
The first  Blood transfusions of record take place. Animal experiments conducted by Richard Lower, an Oxford physician started as dog-to-dog experiments and proceeded to animal-to-human over the next two years. Dogs were kept alive by the transfusion of Blood from other dogs.

9. 1667 - Jean-Baptiste Denis in France reported successful transfusions from sheep to humans.
Transfusion from animals to humans, having been tried in many different ways, was deemed to be unsuccessful, and was subsequently outlawed by the Paris Society of Physicians because of reactions, many resulting in death.

10. Philip Syng Physick, performed the first known human Blood transfusion, although he did not publish the particulars.

11. James Blundell, a British obstetrician, performed the first successful transfusion of human Blood to a patient for the treatment of postpartum hemorrhage. Patient's husband as a donor. Between 1825 and 1830, he performed ten documented transfusions, five of which proved beneficial to his patients, and published these results. He also devised various instruments for performing Blood transfusions.
In London England, Samuel Armstrong Lane, aided by consultant Dr. Blundell, performed the first successful whole Blood transfusion to treat hemophilia.

12. Karl Landsteiner- first three human Blood groups (based on substances present on the red Blood cells), A, B and O.
Hektoen -cross-matching Blood between donors and patients to exclude incompatible mixtures.
Carlo Moreschi -antiglobulin reaction.
1939 and The Rh Blood group system was discovered by Karl Landsteiner, Alex Wiener, Philip Levine and R. E. Stetson

13. The safest transfusion is
HOW SAFE IS BLOOD ?
The safest transfusion is

14. The safest transfusion is the one that is not done
HOW SAFE IS BLOOD ?
The safest transfusion is the one that is not done

15. SAFE BLOOD
Blood that does not include foreign materials or substances which can induce risk or disease in the person transfused with it.
Recipient should have no harm
Donor should not be under risk due to giving blood

16. IS 100 % SAFE BLOOD POSSIBLE ?
Technological insufficiency/ developing technologies (window phase)
Presence of unknown harmful factors s:HIV
s: Prions:Creutzfeldt-Jacob disease?
Avian flu? Swine flu? West Nile virus?
Unknown new viruses

18. SAFE BLOOD CORRECT TRANSFUSION INDICATIONS SELECTING THE DONORS
DRAWING, KEEPING, PROCESSING, CARRYING BLOOD/BLOOD COMPONENTS
INFECTION SAFETY
SAFETY BY SEROLOGICAL TESTS
TRANSFUSION AND FOLLOW-UP

20. BLOOD BANKS/CENTRES AND BLOOD BANKING- Duties
Collecting blood from donors
Preparing blood components
Screening donated blood (microbiological, immunohematological)
Testing the recipients and compatibility tests
Post-testing procedures
Issuing the blood component
Transfusion follow-up

22. BLOOD COMPONENTS
RBC (PRC)
Platelets
Granulocytes
Plasma (Fresh frozen plasma)
BLOOD PRODUCTS
Albumin
Immunoglobuklins
IVIG
Factor VIII
Factor IX

25. TESTS PERFORMED IN BLOOD CENTRES
MICROBIOLOGICAL
IMMUNOHEMATOLOGICAL

26. IMMUNOHEMATOLOGICAL TESTS
Blood groups
ABO, Rh and subgroups, Kell, ....
Antibody screen and identification
Compatibility testing and cross-match
Screening unusal antibodies
Compatibility testing

27. POST-TESTING PROCEDURES
Leukoreduction
Irradiation
Keeping at the blood centre
Issuing blood: Is the issued blood correct? Labelling errors?
Transferring blood to the ward /department
Storage conditions until the time of transfusion (blood refrigerator/ shaker-agitator/ temperature)

28. TRANSFUSION AND FOLLOW-UP
Performing transfusion
Following during transfusion
Transfusion reactions- diagnosis and management
Febrile
Allergic
Hemolytic

29. Blood Group Antigens
A blood group antigen is a hereditary character on red cells that can be detected by specific allo-antibodies.
Structure:
Protein
Glycoprotein
Glycolipid

30. Erythrocyte surface antigens- Blood group systems
Minor
Major
ABO:
A1, A2, B, AB, H
(oligosaccharide)
Rh (CcDEe)
(polypeptide)
Kell
Kidd
Duffy
MNS
Lutheran
Lewis
Diego

31. ABO Blood group testing
Forward grouping: Testing for the antigens on erythrocytes
Reverse grouping: Testing for anti-A, anti-B antibodies in plasma

32. ABO Blood group testing

33. Slide method

34. Slide method

35. Tube method

36. Gel method

37. Forward and reverse grouping
Forward grouping
B antigen (+)
Reverse grouping
Anti-A1 (+)

38. BLOOD GROUP CHOICES

39. Rh (CDE) Blood Group Sytem Antigens
C-c D
E-e
No natural alloantibodies
Examples:
cDE/CDE CcDE
cDe/cDe  cDe
CE/cE  CcE (D negative)

40. Compatibility Testing
Blood grouping (ABO and RhD)
Cross-match
Antibody screening and identification (IAT)
Direct antiglobulin test
Minor blood group antigens

42. Cross-matching

44. Antiglobulin (Coombs) tests

45. Antiglobulin (Coombs) tests

46. SCREENING FOR INFECTIONS
HBV
HCV
HIV
Syphilis
Malaria

47. SCREENING FOR INFECTIONS
Sensitivity -specificity
Confirmation of positive results
Additional tests/ new methods
CMV? Parvovirus B19 ?
Additional tests necessary for unidentified positivities ?
anti-HBc, NAT, PCR

48. WINDOW PHASE ROUTINE NAT HIV 3-38 days 11 days HCV 55-192 days 23 days
HBV
37-87 days
37 days
Syphilis
3 weeks

49. RISK OF INFECTION HBs: 1/63,000 (1/31,000-1/147,000)
HCV: 1/103,000 (1/ /288,000)
HIV: 1/1,493,000 (1/202, /2,778,000)

50. Risk (rate of infectious donations)
Estimated risk of collecting blood during the infectious window period (US repeat donors, post NAT)
Agent
Window Period (days)*
Risk (rate of infectious donations)
HBV - no correction** - corrected**
59 59
1:488,000 1:205,000
HCV - Ab test only - plus NAT
70 70
1:276,000 1:1,935,000
HIV - Ab plus p24 - plus NAT
16 11
1:1,468,000 1:2,135,000
HTLV
51 41
1:514,000 1:2,993,000

51. TRANSFUSION INDICATION AND BLOOD ORDER
Blood orders/ forms:
To be fiiled in fully and correctly
Clinical information needed
Selecting the blood component for the individual patient
WHOLE BLOOD= RAW BLOOD

52. TRANSFUSION INDICATIONS

53. TRANSFUSION INDICATIONS
VOLUME REPLACEMENT ?
ANEMIA ?/ INCREASSING OXYGEN CARRYING CAPACITY?
BLEEDING ?
PREPARATION FOR SURGERY?
INFECTION ?

54. TWO PRINCIPLES OF TRANSFUSION
Do not treat the blood values- treat the patient (e.g. Hb level alone is not always a good indication)
Transfuse the missing/required component only

55. WHICH COMPONENT/PRODUCT?
WHOLE BLOOD ?
ERYTHROCYTES ?
PLATELETS ?
GRANULOCYTES ?
FRESH FROZEN PLASMA ?
PLASMA PRODUCTS ?

56. AUTOLOGOUS TRANSFUSION
Consider for selected cases
Safe
Should not be used for another patient

57. INDICATIONS FOR WHOLE BLOOD
Volume replacement (massive bleeding, shock...)
Exchange transfusion in newborns

58. POST-TESTING PROCEDURES
Leukoreduction
Irradiation
Keeping at the blood centre
Issuing blood: Is the issued blood correct? Labelling errors?
Transferring blood to the ward /department
Storage conditions until the time of transfusion (blood refrigerator/ shaker-agitator/ temperature)

59. WHY LEUKOREDUCTION?
Preventing alloimmunization against leukocytes and platelets
Preventing CMV
Preventing FNHTR
Preventing the immunomodulating effects of transfusion

60. INDICATIONS FOR LEUKOREDUCTION
Thalassemia and hemoglobinopthies
Patiens with or posiblity of SCT
Acute and chronic leukemias
Exchange transfusions and other transfusions in newborns
Platelet function defects
Congenital immune deficiencies
Intrauterine transfusions

61. IRRADIATION WHY? TO PREVENT GVHD INDICATIONS:
Fetal and neonatal transfusions
Immune deficiencies
Allogeneic BMT/SCT
Hematologic malignancies
Aplastic anemia
Solid tumors
AIDS

62. Standard Transfusion Volumes for Children
Blood component
Volume
Expected increase
PRBC
10-15 ml/kg
Hb 2-3gr/dl
PLT
5-10 ml/kg
Platelets X109/L GS
15ml/kg
Clinical response
FFP
10-15ml/kg
%15-20 factor level
Cryoprecipitate
1-2 U/kg
Fibrinogen mg/dl

63. PRBS TRANSFUSION IN CHILDREN
>%25 Blood loss
Hb<8 gr/dl and periop. period
Hb<13 gr/dl and serious cardiopulmonary disease
Hb<8 gr/dl and symptomatic chronic anemia
Hb<8 gr/dl in bone marrow failure

64. PLATELET TRANSFUSION
<5,000-10,000/mm³ with bleeding
<50,000/mm³ and invasive procedure
<2,000/mm³ and BM failure, bleeding risk
Platelet count normal but thrombopathy with bleeding

65. ÇOCUKLARDA TDP END.
Koagulasyon faktör eksiklikleri(konsantreleri yoksa)
Labil koagulasyon faktörlerinin yerine konması ile birlikte kan volüm ekspansiyonu ihtiyacı
Oral antikoagulan toksisitesi(warfarin)
K.C Hast.na sekonder koagulasyon prob.
DİC
Masif tx.na bağlı dilüsyonel değ.
TTP ve HÜS

66. HEMOGLOBİNOPATİLİ ÇOCUKLARDA TX 1
TALASSEMİ
Talasemi Hb.nin globin zincirlerinden bir veya daha fazlasının yapım hızında azalma veya tam yokluğu ile karakterize OR geçen dünyada en sık görülen tek gen bozukluğudur.
Talasemili çocuklar sık ve düzenli tx aldıklarından Fe yüklenmesi, alloimmünizasyon gibi birçok soruna maruz kalmaktadırlar.

67. HEMOGLOBİNOPATİLİ ÇOCUKLARDA TX 2
Talasemide tx yaklaşımı;
Tx dan önce ABO,Rh ve subgrublarına bakılır(Kell,Duffy,Kidd…)
Çok sayıda tx alanda ak tarama ve tanımlama
Pre ve post tx Hb-Hct bakılır
Hastanın durumuna göre 2-6 hft arayla tx gerekir.
Taze ES tercih edilir.
Lökosit filtresi kullanılır

68. KOAGÜLOPATİLİ ÇOCUKLARDA TX
Hemofili ve diğer kanama diyatezi olan hastalıklar ile doğal antikoagulan eks.de eksik olan faktörün yerine konulması ted.nin temelini oluşturur.
Eksik olan faktörün yerine konulması için Tam Kan KULLANILMAMALIDIR.
Eksik faktörün yerine konması için plasma ve plasma ürünlerinden yararlanılır.
KVS normal olan hastalara TDP 15-20ml/kg dozunda 1 saatlik infüzyonla verildiğinde F IX düzeyi Ü/dl artış gösterir.
Faktör konsantreleri ise küçük hacimlerde Ü Koagulasyon faktörleri içerir.

69. ÇOCUKLARDA OTOLOG TX
VA 25kg ve üzerinde olmalı
Fe durumu göz önünde tutulmalı
Toplanacak kan miktarı toplam kan volümünün %12 sini aşmamalıdır
Kan-sitrat oranı uygun olmalı(pediatrik torbalarda 250cc kan için 35ml antikoagülan bulunmaktadır)

70. PEDİATRİDE AFEREZ 1 TERAPÖTİK AFEREZ END.
Eritrositaferez;
Orak.h. anemi
Polisitemi
İzovolemik eritrosit Tx
Lökositaferez;
Lökositoz
Periferik kök hücre toplanması
Plazmaferez;
Dolaşımdaki faktörlerin uzaklaştırılması
Koagulasyon desteği sağlanması
Paraproteinemi
Böb.hast
Hemolitik Anemi
Guillain-Barré
Sistemik lupus

71. PEDİATRİDE AFEREZ 2 PLAZMA DEĞİŞİMİ
Amaç ;
Toksik maddelerin uzaklaştırılması(Ab,
İmmun kompleksler,paraproteinler vs)
Endik.lar; Ailesel hiperkolesterolemi
Paraproteinemi
Hiper IgE ve IgM send.
Gullian Barre send.
Renal Hast.(HÜS ve Good Pasture send)
Hepatik yetmezlik
Ağır Sepsis ve DİC
Otoimmun hast.(OİHA)
Zehirlenmeler
TTP ve
YD da Hiperviskosite

72. APHERESIS
Extracting a component of blood and giving back the remaining to to the patient or donor

73. APHERESIS PRACTICES
1) Donor apheresis
2) Therapeutic apheresis

74. APHERESIS TYPES 1) Cytapheresis a) Leukapheresis b) Platelet apheresis
Peripheral stem cell apheresis
Granulocyte apheresis
Lymphocytapheresis
b) Platelet apheresis
c) Erythrocytapheresis
d) Photopheresis
2) Plasmapheresis
3) LDL apheresis

76. Erythrocytes
Platelets
Granuloytes
Lymphocytes
Monocytes
Plasma

78. DONOR APHERESIS
Preparing blood components from a healthy donor

79. DONOR APHERESIS
Platelets
Leukocytes
Plasma

80. TRANSFUSION AND FOLLOW-UP
Performing transfusion
Following during transfusion
Transfusion reactions- diagnosis and management
Febrile
Allergic
Hemolytic

82. Transfusion Reactions
Acute
(Minutes-Hours)
Late
(Days-Years)
Immune
Hemolytic (1: )
Febrile Non- Hemolytic (%0,5-1)
Urticarial (%1-3)
Anaphylactic (1: )
TRALI (Rare)
Minor Antigen Alloimmunisation (% 1)
Platelet refractoriness
(20-70 % if no leukodepletion)
Graft Versus Host Disease (Variable incidence)
Immunomodulation (Unknown)
Non-immune
Pseudohemolytic (Unknown)
Septic (Unknown)
Circulatory (% 0,01-1)
Metabolic (Unknown)
Embolic (Unknown)
Infectious (Viral, Parasitic, Bacterial)
HBs: 1/205, ,000;
HCV: 1/276,000, HIV: 1/1,468,000
Metabolic( Iron overload)
(Unknown)

83. Findings/symptoms in transfusion reactions
Increase in body temperature ≥1 C; can be with chills
Pain at infusion site, chest, abdomen or flank,
Blood pressure changes; usualy acute hypo- or hypertension
Dyspnea, tachypnea, hypoxemia
Skin manifestations, rash, erythema, urticaria, local or generalized oedema
Acute onset sepsis with fever, severe chills, hypotension, high output heart failure
Anaphylaxis
Nausea which might be accopmpanied by vomiting

84. DURATION of TRANSFUSION
Slow in first 5-10 minutes
Then at a speed which the patient can tolerate
Should not exceed 4 hours
1-3ml/min in children with cardiac failure

85. STORAGE CONDITIONS Whole blood and red cell conc: 4-8 C CPD ; 35 days
SAG-M; 42 days
FFP: -40 C (24 months)
C; 12 months
C; 6 months
C; 3 months
Platelets C; 5 days

86. DONATION CONDITIONS Age 18-65( <) Every 2 months- 4 per year
PLATELET APHERESIS-
24/Year- max. 2/ wk- most frequent 48 hrs
BP / mm Hg HR
Hb 12.5 g/dL

87. If you are going to transfuse me….
Please transfuse if absolutely necessary
Don’t give whole blood if I do not have massive blood loss
Fresh blood not necessary-safe blood essential
Do not get blood from my relatives
Check my blood group even if you know it
Perform all microbiological tests
Take care that the blood in the bag is the same group as mine

88. If you are going to transfuse me….
Please irradiate the blood
Leukoreduce
Cross-match once more at bedside before transfusing
Do not leave me alone while transfusing…
If there is any reaction stop the transfusion immediately and send the blood bag to the blood centre