BLOOD AND ITS COMPONENTS

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BLOOD AND ITS COMPONENTS
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• BLOOD IS VITAL TO LIFE ,OR WE CAN SAY BLOOD IS
  LIFE.
• In INDIA blood transfusion was first started in
  School Of Tropical medicine. Calcutta,1939, with
  out any scope for group matching.
• As this procedure was unscientific a committee
  was formed for establishment of blood bank in
  Calcutta.
• Ultimately a small blood bank was started in the
  dept of Serology, School Of Tropical Medicine
  named as RED CROSS BLOOD BANK.
• Later it was shifted to Maniktala as Central
  Blood bank.
• Pundit Jawhar Lal Nehru donated blood in Calcutta
  in 1946.

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• In spite of dynamic progress in the field medical
  science, the life saving role of blood is yet
  with out parallel, even in the 21st century.
• Blood is still the most essential factor in
  saving a life.
• In INDIA total requirement of blood is
  approximately 80,00,000.units per year, where as
  its collection from voluntary donors does not
  exceed a total of 50,00,000units even after
  almost 60 years of independence.

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Contd.

• In a statistical study it is seen that total no
  of blood donation in
• West Bengal- 713535 (Vol. 85.71)
• Bihar 47863 (Vol. 22.74)
• Jharkhand --- 73238 (Vol. 33.13)
• Uttar Pradesh- 394699 (Vol. 17.3)
• Maharashtra- 377110 (Vol. 86.36)

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Preservation and storage of Blood
Since 1978 citrate-phosphate-dextrose with
adenine (CPDA-1) is used as blood preservative
for 35 days at 2-40C.
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Action of ingredients of anticoagulant solution.
Citrate Prevents coagulation by chelating calcium
Sodium di-phospate Prevents fall in pH
Glucose Supports ATP generation by glycolytic pathways
Adenine Synthesizes ATP, increases level of ATP, extends the self life of RBC to 42 days.
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Action of ingredients of anticoagulant solution.
- Blood pH on day of collection is 7.5 and on
35th day become 6.84. - A fall in pH in the
stored blood results in a decrease in red cell 2,
3-DPG level, which results in increase in
hemoglobin-oxygen affinity. CPDA-1 maintains
adequate levels of 2,3-DPG for 10 -14 days. -
During storage Na and K leak through the red
cell membrane rapidly. K loss is greater than
Na gain during storage.
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Biochemical changes in stored blood
Characteristics Whole blood Whole blood RBC conc. RBC conc.
Days of storage 0 35 0 35
viable cells (24 hrs after transfusion) 100 79 100 71
pH (Measured at 370C) 7.55 6.98 7.60 6.71
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Biochemical changes in stored blood
Characteristics Whole blood Whole blood RBC RBC
2, 3-DPG ( initial value) 100 lt10 100 lt10
Plasma K (m.mol/l) 5.1 27.3 4.2 78.5
Plasma Na (m.mol/l) 169 155 111
Plasma Hb (mg/l) 78 461 82 658
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Transfusion Reactions
Reaction Acute (within 24 hours) Delayed (within days or month
Immune-Mediated Haemolytic Febrile non hemolytic Allergic anaphylactic TR-acute lung injury. Haemolytic Alloimmunization Post transfusion purpura Graft-Vs-host disease
Non-Immune Mediated Bacterial contamination Circulatory overload hyperkalemia Hepatitis B C HIV 12 Syphilis Malaria Iron over load
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Inspection of blood
Blood should be inspected before transfusion for
possible bacterial contamination, haemolysis,
visible clots, brown or red plasma.
Plasma with a green hue should not to be rejected
because this is caused by exposure of bilirubin
pigment to the light.
Yersinia enterocolitica can grow at 40C and the
blood is haemolysed.
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Blood component

• Importance of component separation
• Separation of blood into component allows optimal
  survival of each constituents
• Component separation allows transfusion of only
  specific desired component to the patient
• Transfusion of only the specific constituent of
  the blood avoids the use of unnecessary component
  
• By using blood components several patient can be
  treated with the blood from one donor

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Blood Components (cellular plasma) Plasma
Derivatives

• Cellular components
• Red cell concentrate
• Leucocytes-reduced red cells
• Platelet concentrates
• Leucocytes-reduced platelet concentrates
• Platelet Apheresis
• Granulocytes, Apheresis

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Contd.

• Plasma Components
• Fresh frozen plasma
• Single donor plasma
• Cryoprecipitate
• Cryo-poor plasma
• Plasma derivatives
• Albumin 5 25
• Plasma protein fractions
• Factor viii concentrate
• Immunoglobulin
• Fibrinogen
• Other coagulation factors

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Preparation of blood component is possible due to

• Multiple Poly Vinyl Chloride (PVC) pack system
• Refrigerated centrifuge
• Different specific gravity of cellular components
• Red cells spg. 1.08-1.09
• Platelet spg. 1.03-1.04
• Plasma spg. 1.02-1.03
• Due to different specific gravity of cellular
  components, they can be separated by centrifuging
  at diff g for diff time.

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Centrifugation for blood component preparation

• The components are prepared by centrifuging at
  diff relative centrifugal force at diff time.
• Relative Centrifugal Force in g
• 118 x10-7 x r x N2

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Precautions to be observed in preparing components

• In collection of blood
• proper selection of donor
• Clean aseptic venepuncture site to minimize
  bacterial contamination
• Clean venepuncture with minimum tissue trauma and
  free flow of blood
• The flow of blood should be uninterrupted and
  continuous. If any unit takes more than 8 minutes
  to draw, it is not suitable for preparation of
  blood components.
• A correct amount of blood proportionate to anti
  coagulant should be collected in primary bag that
  has satellite bags attached with integral tubing.

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Contd.

• Monitor the collection of blood with automatic
  mixer which is used for collecting the desired
  amount of blood and mixing the blood with
  anticoagulant
• If platelets are to be harvested the blood bag
  should be kept at room temperature 20-240C until
  platelets are separated. Platelets should be
  separated within 6 hours from the time of
  collection of blood.
• Triple packs system with two attached bags makes
  it possible to make red cells, platelet
  concentrate and fresh frozen plasma. While quad
  packs system with three attached bags are used
  for preparing red cells, platelets concentrate ,
  cryoprecipitate (factor viii) and cryo-poor
  plasma. Double bags are used making red cells and
  Platelet rich plasma only.

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Blood Component Separation

• centrifuge
  centrifuge at 20o freeze -700c
  Whole blood pl.rich plasma
  pl.poor plasma
• 
  
• PRBC
  platelet FFP cryo
• 
  poor plasma
  
  
  
  
• frozen RBC leuco poorRBC
  cryoprecipitate

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Whole Blood

• Whole blood contains 45063 ml or 35049 ml of
  blood plus anticoagulant solution. The
  anticoagulant used is CPDA-1.
• Whole blood has a hematocrit of 30-40 percent.
  Minimum 70 of transfused red cells should
  survive in the recipients circulation 24 hrs
  after transfusion. Stored blood has no functional
  platelets and no labile coagulation factors V and
  VIII.

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Preparation of Red Blood Cell Concentrates

• Red blood cells are prepared by removing most of
  the plasma from a unit of fresh blood.
• Red blood cells preparations are
• Sedimented red cells They have a PCV of 60-70,
  30 of plasma all original leucocytes and
  platelets. Kept at 2-60C.
• Centrifuged red cells They have a PCV of 70-80
  percent, 15 of plasma and all original
  leucocytes and platelets. Kept at 2-60C.
• Red cells with additive (Adsol or SAG-M) They
  have PCV of 50-60 Percent, minimum plasma and all
  leucocytes and platelets. Usually kept at 2-40C.

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Leukocytes-Reduced Blood Components

• Leukocytes in blood components can cause
• Non hemolytic febrile transfusion reactions
  (NHFTR)
• Human leukocyte antigen (HLA) alloimmunisation.
• Transfusion of Leukotropic viruses eg. CMV, EBV,
  HTLV1.
• Transfusion related GVHD
• Transfusion related acute lung injury (TRALI)
• Transfusion related immunosuppression.

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Contd.

• Cytokines are generated by leukocytes, even at
  2-60C but to a much greater extent at 20-240C.
  Cytokine level rise in direct proportion to the
  number of leukocyte. Hence leuko-reduction before
  storage in blood bank is much better than post
  storage bed side leuko-reduction .
• Reducing the leukocyte content lt5x106 in
  one unit of RBCs prevents non hemolytic febrile
  transfusion reactions (NHFTR) and HLA
  alloimmunisation or transmission of CMV.

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Methods of Preparation of Leukocytes-Reduced Red
Cells

• Centrifugation and removing of Buffy coat
• Filtration
• Washing of red cells with saline
• Freezing and thawing of red cells
• leuko-reduction can be done at three diff
  points
• Prestorage leuko-reduction
• Post storage leuko-reduction
• Bedside filtration

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Impact of pre-storage leuko-reduction

• Results from pre-storage Potential patient
  benefit
• leuko-reduction
• Cytokine production is Decrease in NHFTRs
• reduced or eliminated
• White cells are removed Decrease
  alloimmunization
• before fragmentation Decrease virus
  transmission
• Tumor metastasis are Prevent immunomodulation
• reduced .

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Preparation of Platelet Rich Plasma Platelet
Rich Concentrate

• Are prepared from
• 450 ml of fresh blood by centrifugation or
  Aphaeresis.
• A unit of platelet concentrate prepared from 450
  ml of fresh blood contains
• Plasma vol. 40-70ml.
• Platelet yield 5.5x1010
• WBC 108
• RBC traces to 0.5ml.
• pH 6.0 or more

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Calculation of Platelet Yield

• Number of platelet in blood
• platelet per mm3 x1000 x vol. of blood (ml)
• Number of platelet in PRP
• platelet per mm3 x 1000 x vol. of PRP (ml.)
• Number of platelet in P.C.
• platelet per mm3 x 1000 x vol. of P.C. (ml.)
• Calculation
• of platelet yield in PRP
• Number of platelet in PRP x100/ Number of
  platelet in blood
• of platelet yield in P.C.
• Number of platelet in P.C. x100/ Number of
  platelet in PRP

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Precaution and storage

• pH should never fall below 6. A decline in pH
• causes
• Changes in shape of platelets from disc to sphere
• Pseudopod formation
• Release of platelets granules
• The above changes are responsible for low
  recovery and poor survival of platelets in vivo.
• Agitation during storage helps the exchange of
  gases, maintenances of pH, reduce formation of
  platelet aggregates.

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Granulocyte Concentrates

• Granulocyte concentrates prepared by
• Single donor unit
• Leukapheresis by blood cell separators
• As the specific gravity of red cells and
  granulocytes is very similar, the separation of
  granulocytes by centrifugation is not
  satisfactory. Leukapheresis is a better method.
• Granulocytes can be stored at 20-240C but they
  should be used within 8 hrs. not later than 24
  hrs from blood collection.

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Fresh Frozen Plasma (FFP)

• It contains all coagulation factors great care
  must be taken during collection of blood ,
  freezing and thawing to preserve their activity.
• Collection of blood
• Blood should be collected le by a clean, single
  venepuncture.
• Flow of blood should be rapid and constant.
• Total time taken to collect 450 ml of blood
  should not be more than 8 minutes.
• The most labile coagulation factors are
  preserved for one yr. if FFP is kept at -300C or
  below. If FFP is not used within one yr. it is
  redesignated as Single Donor Plasma which can be
  kept further for 4 yrs at -300C or below.
• The FFP should be administered as soon as
  possible after thawing, and in any event within
  12 hrs. if kept at 2-60C.

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Cryoprecipitate

• Cryoprecipitate are precipitated proteins of
  plasma rich in Factor VIII and fibrinogen,
  obtained from a single unit of fresh plasma (
  approximately 200 ml.) by rapid freezing within 6
  hrs of collection.
• Factors improve the yield of Factor VIII in
  Cryoprecipitate
• Clean single venepuncture at first attempt
• Rapid flow of blood, donation of blood (450ml)
  obtained in less than 8-10 mins should be used
• Adequate mixing of blood and anticoagulant
• Rapid freezing of plasma as soon as possible
  after collection in any case within 6-8 hrs after
  collection as done for preparing FFP.
• Rapid thaw at 40C in circulating water bath.
• Storage and shelf life of Cryoprecipitate One
  yr at -300C or below.
• After reconstitution Cryoprecipitate should be
  kept at 2-60C and administered within 4 hrs.

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Single Donor Plasma

• Single donor plasma can be prepared by
  separating it from red cells any time up to 5
  days after the expiration of the whole blood
  unit. When stored at -200C or lower, single donor
  plasma may be kept up to 5 yrs.
• A prolonged pre separation storage period
  increases its contents of potassium ammonia.
• It has no labile coagulation activity.

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Cryoprecipitate Poor Plasma

• It is a by-product of cryoprecipitate
  preparation.
• It lacks labile clotting factors V and VIII and
  fibrinogen.
• It contains adequate levels of stable clotting
  factors II, VII, IX X.
• It is frozen and stored at -200C or lower
  temperature for 5 yrs.

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• Indications, Contraindications Complications of
  Diff Blood Components

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BLOOD TYPES

• Fresh Blood
• Whole blood or RBC concentrates less than 12-24
  hours old form the time of collection are
  considered as Fresh Blood

• Whole Blood
• Blood after 24 hours of collection to 35 days
  are considered as Whole Blood (without platelet
  and labile clotting factor)

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Fresh blood
In new born
exchange transfusion
open heart surgery Hyperkalemia Renal failure
One unit increases 0.8 gm hemoglobin in adult
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Disadvantages of Fresh blood transfusion

1. Chance of transfusion of cytomegalovirus virus,
   Human T- Cell Lymphotropic virus type I II,
   E.B Virus, Treponema pallidum
2. Non hemolytic febrile transfusion reaction
3. Transfusion Related Acute Lung Injury (TRALI)
   results pulmonary oedema

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Cytomegalovirus (CMV)
CMV is a common human pathogen and present in sub
clinical stage in 90 adults. - It is the
common cause of congenital defects eg.
Microcephaly, Intra cerebral calcification,
mental retardation, unilateral or bilateral
hearing loss. Viruses are shed in most of the
body fluids. It infect the mononuclear leucocytes.
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Whole blood
Blood after 24 hours of collection to 35 days
are considered as Whole Blood (without platelet
and labile clotting factor)
Indication

1. Symptomatic decrease in oxygen carrying
   capacity combined with hypovolemia.
2. More than 30 blood loss in acute haemorrhage.
3. Anticipated surgical blood loss more than 1 litre
   .
4. Source of protein with oncotic property.
5. Source of Non-labile coagulation factors.
6. Inoperative blood loss more than 15.

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Whole blood
Disadvantages

1. Less oxygen carrying capacity and more potassium
   accumulation.
2. Low level of 2, 3 di- phosphoglycerate which is
   important in premature neonates, patient with
   impaired cardiac function, haemorrhagic shock,
   respiratory distress syndrome.
3. Develop C.C.F in severe anemic patient.
4. Contraindicated in multiple transfusion

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Whole blood
Complication

• Dilutional thrombocytopenia
• 2. C.C.F

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Red blood cell concentrate
(packed Red Cell) are prepared by removing most
of the plasma from a unit of whole blood.
Indication

1. Urgent operation with haemoglobin less than 10
   gm
2. Anaemia associated with cardiac failure.
3. Haemoglobin less than 6 gm
4. Approaching delivery and haemoglobin less than 7
   gm
5. Liberal guideline in thalassaemia major
6. Anticipated surgical blood loss more than one
   litre

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RBC concentrate
contra-indication

1. Chronic renal failure
2. Pre-operative transfusion to raise hemoglobin
   above 10gm
3. Nutritional Anaemia
4. To enhance general well being, promote healing,
   prevent infection

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Platelet Concentrate
(Production of platelets are approx.
40000/microlitre/day)
1 unit platelet increases 7000/microlitre
platelet count in adult, 80000/microlitre in
infants, 20000 /microlitre in Child of 18 kg body
wt.
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Platelet Concentrate
(Production of platelets are approx.
40000/microlitre/day).
Indication
1. Count less than 5000/microlitre regardless
clinical condition 2. Count is around
20000/microlitre with thrombocytopenic bleeding
or increase risk of bleeding in acute leukaemia
or chemotherapy 3. Count is around
60000/microlitre with DIC or before major surgery.
Administration of ABO incompatible platelet is an
acceptable transfusion practice, but not Rh
incompatible platelet.
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Platelet Concentrate
Complication

1. Chill, Fever, Allergic reaction
2. Infusion of Bacteria
3. Alloimmunisation
4. Platelet refractory state
5. Graft vs. host disease

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Platelet concentrate
contra-indication

1. ITP
2. TTP
3. Heparin induced thrombocytopenia
4. No role in routine open heart surgery
5. Invasive procedure where count is more than
   50000/microlitre
6. Bleeding unrelated to decrease platelet number
   and function.

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Fresh frozen plasma
Indication

1. Actively bleeding and multiple coagulation factor
   deficiency
2. Liver Diseases
3. DIC
4. Coagulopathy in massive transfusion
5. TTP
6. Von Willebrand disease

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Fresh frozen plasma
contra-indication

1. Should not be used as blood volume expander
2. Hypoproteinaemia
3. When prothrombine time is less than 18 second
4. Source of immunoglobin

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Limitations

1. Components must be prepared within 6 hours from
   collection time
2. Needs costly instruments and infrastructures and
   specially trained personnel

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Plasma Derivatives Plasma Substitutes

• Plasma protein solutions
• Plasma protein solutions are prepared from
  pooled plasma after removal of factor viii conc.,
  fibrinogen immunoglobulin
• Albumin preparation
• Albumin 5 soln.
• Albumin 25 soln.
• contain 96 alb 4 globulin
• Plasma protein fraction (PPF) 5 soln.
• Contain 83 alb. 17 globulin

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Characteristics of Albumin Preparation

• The 5 soln. are osmotically and oncotically
  equivalent to plasma, 25 soln. is five times
  that of plasma
• Products are heated and chemically treated to
  reduce the risk of viral disease transmission
  mainly the viruses that have lipid envelope
  eg.HIV1 2, Hepatitis BC, HTLV12
• Shelf life depends on the storage temperature
• room temp----3yrs

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Indications

• 5 albumin PPF
• Blood volume expansion colloid replacement
• Hypoproteinemia following burn extensive
  surgery
• The replacement fluid in therapeutic plasma
  exchange
• Hemorrhagic hypovolemic shock
• Retroperitoneal surgery in which large vol. of
  protein rich fluid may pool in bowel
• 25 albumin
• Severe Hypoproteinemia in acute nephrotic
  syndrome acute liver disease
• Hyperbillirubinemia in the new born
• Toxemia in pregnancy

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Adverse Effect Contraindication

• Adverse effects
• Urticaria and anaphylactoid reactions
• Circulatory overload
• Febrile reactions
• Hypotension due to vasoactive substances in
  plasma
• Contraindications
• Hypoproteinemia in malnutrition
• Chronic Nephrotic syndrome
• Cirrhosis of liver

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Factor VIII Concentrate

• Preparations available
• Factor viii prepared from large pools of plasma
  is sterile , lyophilized
• Commercially prepared by recombinant DNA
  technology
• Storage
• Freeze dried products are stored at 2-60C
• Indications
• Hemophilia A
• Hemophilia A with low levels of inhibitors of
  factor viii
• Von-Willibrand disease

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Immunoglobulin preparation

• Immunoglobulin for IM use
• A concentrated solution of the IgG component of
  plasma prepared from large pools plasma of donors
  containing antibodies against infectious agents
• Indication
• Congenital Hypogammaglobinemia
• Persons exposed to diseases like Hepatitis A or
  Measles

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• Immunoglobulin for IV use
• Indications
• Idiopathic autoimmune thrombocytopenic purpura
• Treatment of immune deficiency states
• Hypogammaglobinemia
• Myasthenia gravis
• HIV related disease

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Contd.

• Hyper immune Globulin
• Used for prevention of diseases like Hepatitis B,
  Varicella Zoster, Rabies, mumps others
• Anti-Rh (D) Immunoglobulin (anti-D RHIG)
• prepared from plasma containing high level of
  Anti-Rh D antibody from previously immunized
  persons.
• Indication To prevent Rh (D) negative mother
  from Rh immunization
• who is pregnant with Rh. (D) positive infant.

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