1. BLOOD COMPONENTS TRANSFUSION INDICATIONS
Dr. Meral SÖNMEZOĞLU
Yeditepe University Hospital
Transfusion Center

2. BLOOD DONATION

5. Differential Centrifugation First Centrifugation
Closed System
Whole Blood
Main Bag
Satellite Bag 1
Satellite Bag 2
First
Platelet-rich
Plasma
RBC’s

6. Differential Centrifugation Second Centrifugation
Platelet-rich
Plasma
RBC’s
Second
Platelet
Concentrate
Plasma
RBC’s

7. Whole Blood
Whole Blood (WB) is blood taken from a suitable donor using a sterile and pyrogen free anticoagulant and container.
W B is a source material for component preparation, which is its major use.
WB for transfusion is used without further processing.
WB for transfusion should not contain irregular antibodies of clinical significance.

8. Whole Blood Storage Indications Considerations 4° for up to 35 days
Massive Blood Loss/Trauma/Exchange Transfusion
Considerations
Use filter as platelets and coagulation factors will not be active after 3-5 days
Donor and recipient must be ABO identical

9. RBC Concentrate
Red Cells is obtained by removal of a major part of the plasma from WB.
Red Cells also contains the greater part of the whole blood leucocytes (about 2.5 to 3.0 × 109 cells) and a varying content of platelets depending on the method of centrifugation.
For the preparation, plasma is removed from Whole Blood after centrifugation

10. RBC Concentrate Storage Indications Considerations
4° for up to 42 days, can be frozen
Indications
Many indications—ie anemia, hypoxia, etc.
Considerations
Recipient must not have antibodies to donor RBC’s (note: patients can develop antibodies over time)
Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
Usually transfuse over 2-4 hours (slower for chronic anemia

11. Function of RBCs Oxygen Transport
Delivery of oxygen from lungs to tissues
Oxygen transport is dependent on
Hematocrit
Cardiac output
Oxygen extraction 11

12. Normovolemic Anemia As hematocrit falls Blood viscosity decreases
Cardiac output increases (Stroke volume,  pulse)
Delivery of O2 
O2 extraction 
Consumption of O2 remains constant 12

13. Limits of Compensation
At very low hemoglobin levels (approximately 4 g/dL)
O2 delivery does not meet demand
Anerobic metabolism  lactic acidosis  cardiac arrest 13

14. Indications for RBC transfusions
Recommended that surgery patients have a hemoglobin of 8 to 10 g/dL
Led to a general rule of hemoglobin > 10 g/dL of surgery patients
1980s
Development of invasive monitoring techniques lead to a better understanding of oxygen delivery and consumption
Lower hemoglobin levels could be tolerated 14

15. Hemoglobin and Hematocrit Levels in Healthy Adults
Hemoglobin (g/dL)
Hematocrit (%)
Mean
-2SD
Female
14.0
12.0 41 36
Male
15.5
13.5 47
Hematology: Basic Principles and Practice. Elsevier 2005 15

16. Transfusion Trigger: Multicenter, Randomized Control Study of ICU Patients
Transfusion Strategy
Hb Trigger
Maintenance Level
Conservative
7.0 g/dL
7.0 to 9.0 g/dL
Liberal
10.0 g/dL
10.0 to 12.0 g/dL
Herbert PC et al. N Engl J Med. 1999;340: 16

17. Cardiac disease patient
Transfusion Trigger: Multicenter, Randomized Control Study of ICU Patients
30-day mortality P
Restrictive
18.7%
0.11
Liberal
23.3%
Less acutely ill
8.7%
0.03
16.1%
Cardiac disease patient
20.5%
0.69
22.9%
Herbert PC et al. N Engl J Med. 1999;340: 17

18. Restrictive vs Liberal Transfusion in Other Conditions
No difference
Pediatric ICU patients
7.0 g/dL vs 9.5 g/dL
Lacroix J, et al. N Engl J Med. 2007:356;
Moderate to severe head injury
7.0 g/dL vs 10.0 g/dL
McIntyre LA et al. Neutrocrit Care 2006;5:4-9
Possible difference
Cardiovascular disease
Liberal transfusions may be better in patients with acute myocardial infarction and unstable angina
Hebert PC et al. Crit Care Med. 2001;29: 18

19. Platelets Storage Indications Considerations Up to 5 days at 20-24°
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

20. Platelets

21. Plasma and FFP
For the preparation, plasma is removed from Whole Blood after centrifugation
It must contain, on average, not less than 70 IU Factor VIII per 100 ml and at least similar quantities of the other labile coagulation factors and naturally occurring inhibitors.

22. Plasma and FFP Contents—Coagulation Factors (1 unit/ml) Storage
FFP—36 months at –35 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%

23. Cryoprecipitate Description Storage Indication Considerations
Precipitate formed/collected when FFP is thawed at 4°
Storage
After collection, refrozen and stored up to 1 year at -18°
Indication
Fibrinogen deficiency or dysfibrinogenemia
vonWillebrands Disease
Factor VIII or XIII deficiency
DIC (not used alone)
Considerations
ABO compatible preferred (but not limiting)
Usual dose is 1 unit/5-10 kg of recipient body weight

24. Granulocyte Transfusions
Prepared at the time for immediate transfusion (no storage available)
Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected
Donor is given G-CSF and steroids or Hetastarch
Complications
Severe allergic reactions
Can irradiate granulocytes for GVHD prevention

25. Leukocyte Reduction Filters
Used for prevention of transfusion reactions
Filter used with RBC’s, Platelets, FFP, Cryoprecipitate
Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions
May reduce RBC’s by 5-10%
Does not prevent Graft Verses Host Disease (GVHD)

26. RBC Transfusions Preparations
Type
Typing of RBC’s for ABO and Rh are determined for both donor and recipient
Screen
Screen RBC’s for atypical antibodies
Approx 1-2% of patients have antibodies
Crossmatch
Donor cells and recipient serum are mixed and evaluated for agglutination

27. RBC Transfusions Administration
Dose
Usual dose of 10 cc/kg infused over 2-4 hours
Maximum dose cc/kg can be given to hemodynamically stable patient
Procedure
May need Premedication (Tylenol and/or Benadryl)
Filter use—routinely leukodepleted
Monitoring—VS q 15 minutes, clinical status
Do NOT mix with medications
Complications
Rapid infusion may result in Pulmonary edema
Transfusion Reaction

28. Platelet Transfusions Preparations
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 RBC’s in Platelet unit may sensitize the Rh- patient

29. Platelet Transfusions Administration
Dose
May be given as single units or as apheresis units
Usual dose is approx 4 units/m2—in children using 1-2 apheresis units is ideal
1 apheresis unit contains 6-8 Plt units (packs) from a single donor
Procedure
Should be administered over minutes
Filter use
Premedicate if hx of Transfusion Reaction
Complications—Transfusion Reaction

30. Serological Testing 3 tests: ABO/Rh Antibody detection/identification
Crossmatch

31. ABO/Rh Typing In the ABO typing, the forward and reverse MUST match
In the Rh typing, the control must be negative
Both of these will indicate what type of blood should be given

33. Blood Grouping using gel cards2

34. Antibody screen and/or ID
The antibody screen will detect the presence of any unexpected antibodies in patient serum
If antibodies are detected, identification should be performed using panel cells (with an autocontrol) IS
37° (LISS)
AHG
If an antibody is present, units negative for the antigen must be given (remember the calculation?)
Proceed to the crossmatch…

35. Crossmatching Purpose: Prevent transfusion reactions
Increase in vivo survival of red cells
Double checks for ABO errors
Another method of detecting antibodies

36. Crossmatch Two types of crossmatches
Major – routinely performed in labs
Minor – not required (by AABB since 1976)

37. Major vs Minor Crossmatch
Why is the minor crossmatch unnecessary?
Donated units are tested for antibodies
Most blood is transfused as packed cells, having little antibodies
Major: Patient serum crossmatched with donor red cells.
Minor: Donor serum crossmatched with patient red cells. Antibody screen testing on donor samples has replaced the minor crossmatch.

38. Crossmatch No agglutination ~ compatible Agglutination ~ incompatible
Donor RBCs (washed)
Patient serum

39. Conclusions
Although RBCs are much safer than 20 years ago, transfusion practices have become more restrictive
The transfusion threshold at most institutions is a hemoglobin of 7 to 8 g/dL for most patients
Higher thresholds are used for specific patients 39

40. TRANSFUSION REACTIONS

41. Transfusion Reactions are…
Adverse reactions associated with the transfusion of blood and its components

42. Transfusion reactions
Non-threatening to fatal
Hemolytic or non-hemolytic – may or may not cause RBC destruction
Acute to delayed
Acute – rapid onset
Delayed – days to weeks
Reactions may involve antigen-antibody interactions
May involve infectious agents

43. Transfusion Fatalities Reported to the FDA (FY 2004 to 2006)43

45. Disease Transmission Hepatitis HIV HTLV Cytomegalovirus Malaria
Babesiosis
Syphilis

46. Infectious Risk of Transfusion
Klein HG et al. Transfusion 2007;47:

47. SHOT 2011 Serious Hazards of Transfusion (SHOT) Steering Group.
The 2011 Annual SHOT Report (2012)

48. SHOT (n=9925)

51. SHOT 2011 Serious Hazards of Transfusion (SHOT) Steering Group.
The 2011 Annual SHOT Report (2012)

52. Enfeksiyon Riski (Türkiye)
2010’da , (56.4%) bağış Türk Kızılay’ı tarafından toplandı.
2005 de 20%.
42% si ilk kez bağışçı olmayandan
Serolojik test pozitifliği 2010;
Sifiliz: 0,10%
HIV : 0,17%
HCV: 0,25%
HBsAg:0,93%

53. Enfeksiyon Riski HBsAg (Türkiye)

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