1. Blood Transfusion
Teoman SOYSAL Prof. MD

2. Blood Donation Healty adult donors
450 ml +/- 10% per whole blood donation
Male: 5/year, Female : 4/year
> 8 weeks between two donations

3. Apheresis:
Platelets
Plasma
White cells (or subsets)
Red cells
The procedure can be done for treatment or transfusion purposes.

4. Blood Preservation Whole blood or red cells
1-Liquid phase storage : 1-6º C
63 ml anticoagulant-preservation liquid/unit
duration of preservation
ACD: 3 weeks
CPD: 3 weeks
CPD-A1: 35 days
RBC concentrate with SAG-Mannitol : 7 weeks
2- Frozen storage of red cells
-80 to º C , with glycerol etc: Years

5. Blood Preservation Effects of storage Red cells: ATP, 2-3 DPG,
osmotic fragility and oxygen affinity
Plasma : Hb, K, NH3 :
pH:
Platelets: Lost in 2 days
Coagulation factors:
Eg:
FV: adequate levels for about 5 days
FVIII: Below 80% of original level after 1-2 days
FXI: Less than 20% of original level after 7 days

6. Blood Preservation Platelets: Plasma : Use fresh or freeze
liquid phase :
1 - 5 days,
room temp.,
avoid light exposure
kept on special agitator
Plasma : Use fresh or freeze
frozen at -18 º C within 8 hrs of collection

7. Blood components & products
Cell containing components
Red cells:
Whole blood( fresh or not)
Red cells: packed red blood cells
washed red blood cells
frozen red blood cells
leukocyte – reduced red blood cells
Platelets: Random donor platelets
Apheresis platelets ( single donor platelets)
Granulocytes or mononuclear cells
Peripheral blood progenitor cells

8. Blood components & products
Plasma and products
Plasma : fresh / fresh-frozen plasma
Cryopresipitate
Coagulation factor concentrates
Immunglobulin preperations
Albumin
others

9. White cell reduction White blood cell filtered or,
Washed red cells or,
Frozen red cells
are white cell reduced red blood cell components.

10. Deciding blood transfusion;
Severity of symptoms
Cause of anemia
Rapidity of anemia or symptoms
Co-morbidities and the age of the patient
Can we treat the anemia without transfusion?
And
Is there enough time to wait for the response of such a treatment ?

11. This is not a guide to be used in every patient
Hemoglobin >10 g/dL : Tx rarely needed
Hemoglobin < 6-7 g/dL: Tx mostly necessary
Hemoglobin : 6-10 g/dL: Dependable

12. Important:
Symptoms related to anemia may differ from one patient to another for a given Hb level;
The trigger for red cell transfusion may differ from one patient to another!!!!!

13. Indications for transfusion of blood or its components
Whole blood: Acute massive bleeding
1 unit increases Hb: 1g/dl, Hct: 3%
Fresh whole blood:
Massively bleeding patient/shock
Exchange transfusion, open heart surg, severe renal or hepatic failure,
Red blood cells:
(To increase the oxygen carrying capacity in case of symptomatic anemia not treatable by other means or due to urgency of symptoms)
Symptomatic anemia (May be due to different causes), post-bleeding hypovolemia

14. Indications for transfusion of blood or its components
White cells reduced RBC’s:
< 5x106 WBC’s per unit
White cell filters
(before storage or before transfusion)
An indication for RBC transfusion +
To prevent reactions caused by WBC antibodies
Febrile non-hemolytic transfusion reactions
To prevent alloimmunization
To prevent CMV transmission

15. Indications for transfusion of blood or its components
Washed RBC’s:
An indication for RBC transfusion +
Any need to prevent the recipient allo-immunisation to WBC’s , plasma antigens or any contraindication to infuse complement
PNH
IgA deficiency
Prevention of anaphylaxis
Washed units must be transfused no later than 24 hours
Frozen RBC’s:
Autologous transfusion: rare blood groups,
Catastrophy etc
Washed before infusion !!

16. Indications for transfusion of blood or its components
Blood Irradiation
To prevent transfusion related GVHD in;
Congenital immune deficient states
Bone marrow or stem cell transplantation
Some cases of hematologic malignancies
Hodgkin’s disease
Purin analogue or anti-CD52 treatment
Intra-uterin transfusion
New borne exchange transfusion
Transfusions between relatives
first or second degree
HLA matched platelets

17. Some of the indications for platelet transfusions
Decreased platelet production because of bone marrow failure or infiltration :bleeding or risk of bleeding
Leukemia
MDS
Myelofibrosis
Malignant tm infiltration
Myelosupression
Aplastic anemia
Functional platelet disease and bleeding or risk of bleeding
Dilutional thrombocytopenia (after massive transfusion)
Cardiac by-pass surgery
Increased platelet destruction or consumption
DIC
Drug induced
sepsis
ITP

18. Indications for transfusion of blood or its components
Platelets:
Thrombocytopenia due to decreased platelet production
Platelet count/mm Bleeding /surgery Indication for plt transfusion
> , No No
< Yes Yes
No No
(if there is bleeding/fever/DIC/plt dysfunction) Yes
< Yes or No Yes

19. Some special conditions about platelet transfusion
Disease status may change
the transfusion effectiveness:
DIC
Hypersplenism
Sepsis
Allo-immunisation
Cotraindicated in Thrombotic
Thrombocytopenic Purpura: Used
only in high risk bleeding
Not effective/useful in Immune
Practical issues
ABO matched platelets have a longer in-vivo life span after transfusion
Use Rh- platelets for Rh- recipients (to prevent Rh immunisations) or use anti-Rh(D) Ig if Rh+ component used in such recipients

20. Types of platelet concentrates
Random donor plt concentrate (single unit)
5,5 x 1010 plts
/mm3 plt increase after transfusion
Pooled plt concentrate (eg:6 random units)
Apheresis plts
>3x1011 plts
/mm3 increase after transfusion
WBC reduction of platelets is indicated in the same situations like red cells.

21. Indications for transfusion of blood or its components/products
Fresh frozen plasma ( contains all coag. Factors)
Congenital or acquired coag.Factor deficiency (bleeding or surgery)
Oral anticoagulant overdose
Plasma exchange (eg:TTP)
After massive transfusion
10-20 ml/kg : to increase deficient factor level about 20-30% from baseline

22. Indications for transfusion of blood or its components/products
Cryoprecipitate
Includes FVIII, vWF, FXIII, fibrinogen and fibronectin
units of FVIII,
≥150 mg fibrinogen and % of FXIII that is in one unit of plasma
Can be used for the purpose of replacing the deficient state of these factors in case of bleeding or surgery

23. Practical Issues
Is there a need for transfusion?
Which product should be used?
Number of units?
Re-check the blood types of the patient and donör and be sure about the cross match
Read label, ID, inspect the product
Is irradiaton necesssary?
Temperature?
Filters?
Flow rate ? (start 5 ml/min-15 minutes , the rest ml/hr)
Drugs ?

24. Transfusion Reactions
Immunologic reactions
Non-immune reactions or
Acute reactions
Late reactions

25. Hemolytic reactions Reasons: Mismatched transfusion
Transfusion of hemolysed blood
During storage or warming etc
May be acute or late

26. Acute hemolytic reaction
Frequency up to 1/25.000
1/ Tx mortal
40% symptomatic
ABO mismatch
IgM antibodies (anti-A or anti-B) ,complement binding and intravascular hemolysis
Early onset ( first ml’s),seldom after 1-2 hrs
pain at the infusion site, flushing, chest or back pain,dyspnea,vomiting, fever-chills, hypotension and tachicardia,bleeding, hemoglobinuria
Complications: Acute Renal Failure, shock,DIC

27. Acute hemolytic reaction
Stop transfusion,
Take measures to keep normal BP and urine output: hydration/diuretics,
Re-check groups, re-cross, take blood cultures,
Follow signs of hemolytic anemia, antiglobulin tests,renal function and DIC tests,
Treat accordingly (eg: dialysis/ICU etc)

28. Delayed hemolytic reaction
1/2500-1/6000
Onset: 3-21 days after transfusion
Reason: Rh, Kidd etc mismatches
Previous alloimmunization and anamnestic response
Coombs + ( do not confuse with OIHA)
Jaundice or absence of the expected increase in red cell values.
Frequently undetected
Treatment : none

29. Febrile reactions 0,5- 3% of all transfusions
Cause: Antibodies against white cell/plt/plasma antigens
Fever-chills, increased pulse rate during or after transfusion
Antipyretics/antihistamines
Stop transfusion if there is doupt about hemolysis
Prophylaxis: White cell reduction

30. Allergic reactions Cause:Antibodies against donor plasma proteins
Pruritus,urticaria,edema,anaphylaxis,bronchospasm
IgA deficient patients are under the greatest risk
Treat according to the type of reaction
For IgA deficient patients: use washed or frozen red cells instead of regular red cells or whole blood.

31. Pulmonary hypersensitivity reaction/TRALI
1/5000 frequency
Cause : Leukocyte incompatibility and agglutination of white cells inside the pulmonary vascular area leading to complement activation and endothelial damage- pulmonary edema.
Fever-chills,tachycardia,chest pain, hemoptysis,
BP fall within 4 hrs of transfusion
Respiratory support may be necessary

32. Transfusion Related Graft- versus -Host Disease
Cause: Immune deficient recipient transfused with viable lymphocytes which are engrafted and start allo-reaction against mismatched HLA and other antigens of the recipient.
High fatality with skin,liver and gut symptoms, pancytopenia and infections
Prophylaxis: Blood irradiation
Treatment: immunosupressive drugs
Mortality high

35. Circulatory overload
Old aged or premature/ new borne or patients with cardiopulmonary compromise are under risk.
Clinics: Acute heart failure
Treatment: As acute myocardial failure
Prophylaxis: Slow infusion rate, low volume of transfusion

36. Bacterial Contamination
Bacterial contamination may cause a reaction with symptoms resembling Acute Hemolytic Reaction without LAB findings of hemolysis.
May be fatal:
Mortality: Plt constr: 1/ – 1/65.000
Red cells: <1/
Stop transfusion, take cultures, treat with IV fluids and antibiotics , take support measures and follow against shock, renal failure,DIC

37. Air embolism May cause acute respiratory and circulatory failure
Clump the tubing
Change the posture of the patient:
Left side / Trandelenburg (left side ,head- down, legs upside)
Swan -Ganz catheter

38. Massive transfusion may cause:
Patients with bone marrow failure , transfused chronically are under the risk of transfusion hemosiderosis.
Massive transfusion may cause:
Citrate toxicity: Hypocalcemia
Hyperkalemia
Bleeding ( due to thrombocytopenia and /or factor deficiency)

39. Transfusion transmitted pathogens
Hepatitis ( C,B,A ,D etc )
HIV
HTLV
CMV
E-Barr
HHV
Creutzfeldt-Jakob or
variant CJD (therotical)
Parvovirus
Malaria
Lyme ? (not enough evidence)
Chagas
Babesiosis Sy
Toxoplasmosis
West Nil virus