1. Principles of BLOOD TRANSFUSION
RONALD A. HUKOM
DIVISI HEMATOLOGI & ONKOLOGI MEDIK, DEPARTEMEN ILMU PENYAKIT DALAM,
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA / RUMAH SAKIT KANKER DHARMAIS - Jakarta

2. History
1818 – the first human-to-human transfusion takes place….unfortunately patient dies
1901 – Karl Landsteiner discovers blood groups
1907 – checking for incompatibilities (crossmatching) is performed and leads to less transfusion reactions (N=128)
1916 – a citrate-glucose solution is developed to prolong the life of stored blood (weeks)

3. History
1917 – the first blood depot is formed with Group O blood for casualties in World War I
– more blood donor and transfusion services are established and the term “blood bank” is coined
– Rh system discovered
World War II begins….

4. History
1940 – Plasma of Britain campaign begins after a shortage of plasma in WWII; plasma separation methods are first used
1941 – the American Red Cross organizes a civilian blood donor service for WWII +

5. History 1960’s – Factor VIII concentrate developed for hemophiliacs
1971 – Blood banking becomes regulated by the FDA
1980’s – dozens of blood recipients develop what is now called AIDS
1980’s to present – more sensitive tests have been developed to screen donors (hepatitis and HIV)

6. Blood Donation Parts of the donation process: Donor screening
Physical exam and medical history
Blood collection
Phlebotomy, adverse reactions, blood labeling
Special donors
Directed donation, autologous donation, hemapheresis, and therapeutic phlebotomy

7. Blood Donation Most blood donations are allogeneic
Allogeneic donations are used for the general population
Donors are not paid for donations; nor are they required to donate
Donor centers must keep a record on each donor for at least 10 years

8. ABO Blood Groups Based on 2 Antigens (agglutinogens)
4 blood types: A, B, AB, O
Blood antigens are genetically coded located on the surface of RBC membrane
Antigen found on RBC corresponds to blood type.

9. Blood Groups
TYPE ANTIGEN PRESENT
A A
B B
AB AB
O Neither A nor B

10. Blood Groups
Antibodies are called agglutinins they develop after birth in the plasma
You will have the antibody for the antigen that is NOT present.
If you have A blood you have the A antigen on your RBC, and you will develop the B antibody

11. Antibody TYPE ANTIGEN ANTIBODY A A anti B B B anti A AB AB neither
O neither anti A antiB

13. BLOOD TYPE PERCENTAGE
O %
A %
B %
AB %

14. A reaction outside the body between antigens and antibodies result in agglutination which means the blood cells clump together.
A reaction within the body between antigens and antibodies results in hemolysis which means the red cells burst

15. Rh Factors
1946 Landsteiner, Levine and Weiner did research on the rhesus monkey and developed the Rh factor
Three genes code for the antigen on red cells- C, D, E

16. Blood Types based on Rh
Rh positive means the Rh antigen is present on the RBC (+)
Rh negative means the Rh antigen is not present on the RBC (-)

17. Rh negative people that receive Rh positive blood, will trigger the immune system to develop Rh antibodies, that will remain in the blood

18. Erythroblastosis Fetalis
Hemolytic Disease of the Newborn
A Rh negative mom may be exposed to an Rh antigen from the blood of a Rh positive baby during pregnancy or birth.
If Rh + cell enters Rh- mom, the mother’s immune system will respond and produce antibodies against the Rh positive blood antigen

19. In pregnancies thereafter Rh antibody may cross the placenta, and cause RBC hemolysis in fetus. The baby will be anemic and very ill.
This can be avoided by giving a Rh- mom antibodies, in the form of a RhoGam shot within 72 hours after delivery of every Rh+ child

20. Donor Screening Registration
AABB Standards require that the donor be linked to the donor records (photo ID)
Required information:
Name (first, last, MI)
Date and time of donation
Address
Telephone
Gender
Age (date of birth) – allogeneic donors must be at least 17 years of age

21. Drugs
Aspirin, piroxicam, Plavix®: if taken within 3 days (some say 48 hours), you cannot donate platelets by apheresis; however, whole blood donations are acceptable. Remember: aspirin effects platelet function (inhibits cyclooxygenase); Plavix blocks ADP receptors on platelets
Chemotherapy: wait 4 weeks from last dose
Human Growth hormone: permanent deferral
Heparin or Coumadin: wait at least 5 days after discontinuing therapy (or until clotting is regulated)
Piroxicam - NSAID

22. Have you donated blood in the last 8 weeks?
The time interval between allogeneic whole blood donation is 8 weeks
A donor must wait 48 hours after donating platelets / plasma, before donating whole blood

23. Physical Examination
General Appearance (donations are now accepted from those 16 yrs old)
Weight
Temperature
Pulse
Blood Pressure
Hemoglobin
Skin Lesions

24. Physical Exam: General Appearance
The donor should not show:
Intoxication
Drug-induced mental impairment
Signs of infection
Skin lesions on arms (IV drug use)
Should appear alert

25. Physical Exam: Weight
Hypovolemia is a decrease in intravascular blood volume
A minimum weight limit of 110 lbs. is used to avoid hypovolemia
This means the maximum amount of blood that can be removed is 10.5 mL/kg of donor weight (donor unit including tubes for testing)
Each bag can hold 450 or 500 mL of blood
Adjustments can be made if patient is small

26. Physical Exam: Hemoglobin
Hemoglobin can quickly be obtained from a finger stick
Hemoglobin should be high enough to support mL of blood
Hemoglobin should be ≥12.5 g/dL
Hematocrit should be ≥38%
3 times rule  12.5 g/dL X 3 = 37.5% or 38%

27. Hemoglobin Testing
Copper sulfate method or point-of-care instruments using a spectrophotometric method
Copper sulfate method:
Solution of CuSO4 has a specific gravity of 1.054
The SG of blood correlates with the hemoglobin
A small blood sample is dropped in the solution to see if it floats or sinks
Difficult to dispose of, so the test may eventually be replaced

28. Informed consent
Before donation, a donor must provide informed consent
If for any reason a donor doesn’t think their blood is safe to donate, they may affix a barcoded sticker to the unit indicated it should not be used
It is all kept confidential….

29. BLOOD COMPONENT RED BLOOD CELLS SUSPENSION (PACKED RED CELLS)
THROMBOCYTE CONCENTRATE
SUSPENSI GRANULOSIT (BUFFY-COAT)
PLASMA AND DERIVATE (F.F.P., CRYOPRECIPITATE, FACTOR VIII/IX, ALBUMIN, etc.)

30. TRANSFUSION MEDICINE RATIONAL USE OF BLOOD COMPONENT
DONOR (ALLO / AUTO-TRANSFUSI)
GOALS, NO EXCESSIVE USE OF BLOOD COMPONENT
SAFETY, TRANSFUSION SIDE EFFECT AND PREVENTION EFFORTS

31. RATIONAL BLOOD TRANSFUSION
PREVENT DANGER
EFFECTIVE (TUJUAN TERCAPAI)
EFFICIENT (TIDAK ADA PEMBOROSAN / PENGHAMBURAN KOMPONEN DARAH)

32. IRRATIONAL BLOOD TRANSFUSION
DARAH/KOMPONEN DARAH TIDAK TERPAKAI, PEMBOROSAN DARAH
DANA DARI DONATUR, MASYARAKAT, PEMERINTAH TERBUANG
KEBUTUHAN DARAH MENINGKAT
BIAYA DAN BAHAYA UNTUK PASIEN MENINGKAT
KEBUTUHAN DONOR MENINGKAT - DONOR KOMERSIAL
MALPRACTICE ?

33. RISK OF BLOOD TRANSFUSION
IMMUNE REACTION
NON-IMMUNE REACTION
DISEASES (HBV, HCV, HIV, CMV, S.T.D., MALARIA)
IMMUNOSUPPRESSION

34. RED BLOOD CELLS TRANSFUSION SIDE EFFECTS
ALLOIMMUNIZATION OF LEUCOYTE AND/OR THROMBOCYTE = 1:10
ALLOIMMUNIZATION OF ERYTHROCYTE = 1:100
NON-HEMOLYTIC FEVER REACTION = 1:100
VIRAL HEPATITIS = 1:250
LATE TRANSFUSION REACTION = 1: 2500
ACUTE (HEMOLYTIC) TRANSFUSION REACTION = 1:100,000
H.I.V. INFECTION < 1:250, (Jain, 1992)

36. POST-TRANSFUSION G.V.H.D.
DAPAT MEMBAHAYAKAN JIWA DALAM 3-4 MINGGU
PERLU SELALU DIINGAT PADA KEADAAN APLASIA SESUDAH RADIASI / KEMOTERAPI DOSIS TINGGI, USIA > 65 TAHUN, PASIEN LEKEMIA DAN LIMFOMA
PENCEGAHAN: RADIASI KOMPONEN DARAH

37. Irradiation of Blood Components

38. Irradiation of Blood Components
Cellular blood components are irradiated to destroy viable T- lymphocytes which may cause Graft Versus Host Disease (GVHD).
GVHD is a disease that results when immunocompetent, viable lymphocytes in donor blood engraft in an immunocompromised host, recognize the patient tissues as foreign and produce antibodies against patient tissues, primarily skin, liver and GI tract. The resulting disease has serious consequences including death.
GVHD may be chronic or acute

39. ‘LEUCOCYTE-POOR’ RED BLOOD CELLS
PREVENTS NON-HEMOLYTIC FEVER AND ALLOIMMUNIZATION
TECHNIQUE: RADIATION, WASHING, FILTRATION, CENTRIFUGING, SEDIMENTATION, FREEZING

40. FRESH FROZEN PLASMA (F.F.P.)
PLASMA – CENTRIFUGE, IMMEDIATELY FROZEN ( - 80 C )
VOLUME 1 UNIT = ML
INITIAL DOSE (ADULT, 70KG): UNIT, EVERY HOURS AS INDICATED
IMPORTANT: ‘SHORT HALF LIFE’

41. FREH FROZEN PLASMA (F.F.P.)
COAGULATION FACTOR DEFICIENCY
MASSIVE BLOOD TRANSFUSION
BLEEDING DUE TO WARFARIN
SOMETIMES USED ALSO FOR D.I.C. AND THROMBOLYTIC OVER DOSAGE

42. CRYOPRECIPITATE
RICH IN FACTOR VIII, FIBRINOGEN, PLUS FACTOR XIII, FACTOR VON WILLEBRAND
INDICATION: HYPOFIBRINOGENEMIA, HEMOFILIA-A, AND VON WILLEBRAND DISEASE
dose: 1-4 unit / 10 KG

43. Platelet Concentrate
Plasma
RBCs
PRP
Platelet concentrate

44. Pooling Platelets 6-10 units transferred into one bag
Expiration = 4 hours

45. PROPHYLACTIC THROMBOCYTE TRANSFUSION
N.I.H. CONSENSUS CONFERENCE (1987) : THROMBOCYTE LESS THAN /MM3, HIGHER LEVEL FOR SYSTEMIC BLEEDING OR PATIENTS WITH HIGHER BLEEDING RISKS

46. Apheresis
Apheresis involves the removal of whole blood, separating specific components, and returning the unused portion back to the donor
Plateletpheresis (no more than 2x per week)
Plasmapheresis (tested for protein and Ig; 2x wk)
Leukopheresis (uses components to stimulate granulocytes; hydroxyethyl starch, steroids, G-CSF)
Double RBC pheresis (2 units every 16 weeks)

48. Apheresis Platelet Concentrate
Used to decrease donor exposure, obtain HLA matched platelets for patients who are refractory to RD-PC or prevent platelet refractoriness from occurring.
Prepared by hemapheresis.
One pheresed unit is equivalent to 5-6 RD-PC.
Store at C (RT) with agitation for 5 days.
D negative patients should be transfused with D negative platelets due to the presence of a small number of RBCs

49. Apheresis Platelet Concentrate
One bag (unit) from one donor
One unit is a therapeutic dose
Volume approximately 250 ccs

50. THROMBAPHERESIS
ADVANTAGE: PREVENTS AUTO-ANTIBODY IN MULTIPLE RANDOM DONOR TRANSFUSION
BEST FOR PATIENTS WITH AGGRESSIVE CHEMOTHERAPY (e.g. ACUTE LEUKEMIA), BONE MARROW TRANSPLANTATION / P.B.S.C.-T

53. Blood Typing
Blood typing is when blood samples are tested with known antiseras that contain known antibodies

54. Cross Matching
Cross matching is where typing the donor’s RBC’s are mixed with the recipients serum to check for compatibility before a blood transfusion

55. Blood blank practices #Crossmatching (50 min)
Confirms ABO and Rh typing
Detects antibodies to the other blood group systems
Detects antibodies in low titers or those that do not agglutinate easily

56. # Antibody screen : Indirect Coombs test
Blood blank practices
# Antibody screen : Indirect Coombs test
(45 mins)
the subject serum + red cells
( antigenic composition) red cell agglutination
# Type&screen
# Emergency transfusion

57. Type and screen vs Type and crossmatch
T&S -determines ABO and Rh status and the presence of most commonly encountered antibodies – risk of adverse rxn is 1:1000
-takes about 5 mins
T&C -determines ABO and Rh status as well as adverse rxn to even low incidence antigens – risk of rxn is 1:10,000
-takes about 45 mins

58. Type and screen vs Type and crossmatch:
T&S:
Type O red cells are mixed with pt serum Antibody screen
T&C
Donor red cells are then mixed with the pt’s serum to determine possible incompatibility

59. Immunomodulatory effects of transfusion
Wound infection: circumstantial evidence (? leukocyte filters for immunocompromised)
Beneficial effects on renal graft survival (now < NB with CyA)
97: 9% graft survival advantage after 5 years
Nonspecific overload of RES
 lymphocytes, APCs
Modification T helper/suppressor ratio
Allogeneic lymphocytes may circulate for years after transfusion

60. INFECTIOUS COMPLICATIONS
I. Viral (Hepatitis 88% of per unit viral risk)
Hepatitis B
Risk 1/ 200,000 due to HBsAg, antiHBc screening (7-17 % of PTH)
Per unit risk 1/63-66,000
0.002% residual HBV remains in ‘negative’ donors (window 2-16 weeks)
Anti-HBc testing retained as surrogate marker for HIV

61. NANB and Hepatitis C
Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/ 125,000 with 3rd generation HCV Ab/ HVC RNA tests
Window 4 weeks
70 % patients become chronic carriers, % develop cirrhosis

62. HIV
Current risk 1/ ,000 (95)
With current screening (Abs to HIV I, II and p24 Ag), window 6-8 weeks (third generation ELISA tests in Europe)
 sero -ve window to < 16 days

63. HTLV I, II Only in cellular components (not FFP, cryo)
Risk 1/ 641,000 (window period unknown)
Screening for antibody I may not pick up II
CJD (and variant CJD)

64. CMV Cellular components only
Problem in immunocompromised, although 80 % adults have serum Ab
WBC filtration decreases risk of transmission
CMV -ve blood:
CMV -ve pregnant patients, LBW neonates, CMV -ve transplant recipient,
CMV-ve/ HIV +ve

65. II. Bacterial III. Protozoal
Contamination unlikely in products stored for > 72 hours at C
gram –ve, gram +ve bacteria
most frequent – Yersinia enterocolitica
Produced endotoxin
Platelets stored at room temperature for 5 days, with infection rate of 0.25%
III. Protozoal
Trypanosoma cruzi (Chaga’s disease)
Malaria
Toxoplasmosis
Leishmaniasis

66. Serological Testing for Infectious markers
HIV – Ag
Anti – HIV
HBsAg
Anti – HCV
Test for syphilis

67. TRANSFUSION REACTIONS
is any unfavorable transfusion-related event occurring in a patient during or after transfusion of blood components

68. TRANSFUSION REACTIONS
@RBC’s !
Nonhemolytic 1-5 % transfusions
Causes -Physical or chemical destruction of
blood: freezing, heating, hemolytic drug
-solution added to blood
-Bacterial contamination
: fever, chills, urticaria
Slow transfusion, diphenhydramine , antipyretic for fever
Hemolytic
Immediate: ABO incompatibility (1/ 12-33,000) with fatality (1/ ,000)
Majority are group O patients receiving type A, B or AB blood
Complement activation, RBC lysis, free Hb (+ direct Coombs Ab test)

69. Acute Hemolytic Transfusion Reaction
Pathophysiology
Ab (in recipient serum) + Ag (on RBC donor)
-Neuroendocrine responses
-Complement Activation
-Coagulation Activation
- Cytokines Effects
Acute hemolytic transfusion reaction

70. Acute Hemolytic Transfusion Reactions
Acute onset within minutes or 1-2 hours
after transfuse incompatible blood
Most common cause is ABO-incompatible
transfusion

71. Signs and Symptoms of AHTR
Chills , fever
Facial flushing
Hypotension
Renal failure
DIC
Chest pain
Dyspnea
Generalized bleeding
Hemoglobinemia
Hemoglobinuria
Shock
Nausea
Vomitting
Back pain
Pain along infusion vein

72. @WBC’s! Febrile reactions
Europe: All products leukodepleted
USA: Initial FDA recommendation now reversed pending objective data (NOT  length of stay for  expense)
Febrile reactions
Recipient Ab reacts with donor Ag, stimulates pyrogens (1-2 % transfusions)
% of platelet transfusions
Slow transfusion, antipyretic, meperidine for shivering

73. TRALI (Transfusion related acute lung injury)
Donor Ab reacts with recipient Ag (1/ 10,000)
noncardiogenic pulmonary edema
Supportive therapy

74. Transfusion-related Acute Lung Injury (TRALI)
Pathophysiology:
Leukocyte Ab in donor react with pt. leukocytes
Activate complements
Adherence of granulocytes to pulmonary endothelium with release of proteolytic enz.& toxic O2 metabolites
Endothelial damage
Interstitial edema and fluid in alveoli

75. Transfusion-related Acute Lung Injury (TRALI)
Acute and severe type of transfusion reaction
Symptoms and signs:
Fever
Hypotension
Tachypnea
Dyspnea
Diffuse pulmonary infiltration on X-rays
Clinical of noncardiogenic pumonary edema

76. Transfusion-related Acute Lung Injury (TRALI)
Therapy and Prevention:
Adequate respiratory and hemodynamic supportive treatment
If TRALI is caused by pt. Ab  use LPB
If TRALI is caused by donor Ab no special blood components

77. Transfusion-associated Graft-versus-Host Disease ( TA-GVHD)
Rare: immunocompromised patients
Suggestion that more common with designated donors
BMT, LBW neonates, Hodgkin's disease, exchange Tx in neonates

78. Transfusion-associated Graft-versus-Host Disease ( TA-GVHD)
Pathophysiology
Infusion of Immunocompetent Cells
(Lymphocyte)
Patient at risk
proliferation of donor T lymphocytes
attack against patient tissue

79. Graft-versus-Host Reaction
Signs & Symptoms
Onset ~ 3 to 30 days after transfusion
Clinical significant – pancytopenia
Other effects include fever, liver enzyme,
copious watery diarrhea,
erythematous skin erythroderma
and desquamation

80. @Platelets! Alloimmunization Post-transfusion purpura
50 % of repeated platelet transfusions
Ab-dependent elimination of platelets with lack of response
Use single donor apheresis
Signs & Symptoms
mild  slight fever and Hb
severe  platelet refractoriness with bleeding
Post-transfusion purpura
Recipient Ab leads to sudden destruction of platelets 1-2 weeks after transfusion (sudden onset)
Rare complication

81. METABOLIC COMPLICATIONS
Citrate toxicity
Citrate (3G/ unit WB) binds Ca2+ / Mg+
Metabolized liver, mobilization bone stores
Hypocalcemia ONLY if > 1 unit/ 5 min or hepatic dysfunction
Hypotension more likely due to  cardiac output/ perfusion than  calcium (except neonates)
Worse with hypothermia/ hepatic dysfunction

82. Hyperkalemia After 3 weeks, K+ is 25- 30 mmol/l
Only mmol per unit PRBC/ WB
Concern with > 1 unit/5 infants

83. Acidosis Acid load after after 3 weeks 30-40 mmol/l (pH 6.6 - 6.9)
Metabolic acidosis more likely due to decreased perfusion, hepatic impairment, hypothermia
NaHCO3 or THAM if base deficit > 7-10 mEq/l

84. THANK YOU
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