Blood Transfusion Review

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Blood Transfusion Review

• Salwa Hindawi
• Medical Director of Blood Transfusion Services
• KAUH

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Donor Patient
The risks associated with transfusion can be
reduced by - Effective blood donor
selection. - Screening for TTI in the blood
donor population. high quality blood
grouping, compatibility testing. - Component
separation and storage. -
Appropriate clinical use of blood and blood
products. - Quality assurance
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Blood Donation

• WB every 8 weeks, Hct gt 38
• Plateletpheresis every 3 days or 24 times per
  year, Hct gt 38
• Autologous Blood
• WB every 3 days
• up to 3 days prior to surgery
• Hct gt 33

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Steps in Blood Banking

• Type and Screen (T S) (Done for low
  probability of transfusion)
• ABO and Rh type
• Antibody screen
• Antibody identification
• DAT
• Type and Crossmatch (T C) (Done for high
  probability of transfusion)
• above steps plus Crossmatch

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Direct Antiglobulin Test (DAT)

• also called the direct Coombs test
• adding anti-IgG to detect IgG that is attached to
  the RBCs
• also detects C3 complement fragments on the RBC
  surface
• DAT is performed in the investigation of immune
  hemolytic anemia and transfusion reactions

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Indirect Antiglobulin Test (IAT)

• detects free antibodies in the serum
• the IAT test is performed during the antibody
  screen and antibody identification

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Type and Screen (T S)

• an ABO and Rh type and an antibody screen and
  antibody identification are done when the patient
  is admitted
• only testing necessary if low probability of
  transfusion

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Antibody Screen (IAT)

• recipients serum is added to 3 test RBCs (in test
  tubes 1 to 3 ) which have all of the important
  RBC antigens on them
• therefore if one or more of the three screening
  cells is positive then a RBC antibody is present
  in the serum
• then do an antibody panel to identify the
  antibody present

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Antibody Identification (IAT)

• after the screening RBCs are positive then do an
  antibody identification
• recipients serum is added to 10 test RBCs in a
  panel (test tubes 1 to 10) which contain all of
  the important antigens
• the antibody in the serum is identified

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Major Crossmatch (Compatibility testing)

• donor RBCs (unit of blood) are tested with
  recipient serum
• to detect unexpected recipient antibodies
• this checks to see if the transfusion is
  compatible

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Type and Cross (T C)

• includes an ABO and Rh type and antibody screen
  and antibody identification
• in addition includes a crossmatch where specific
  units of blood are held back for up to three days
  for a particular patient
• for a high probability of transfusion

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Crossmatch to Transfusion ratio (CT ratio)

• blood is used more efficiently when the number of
  units set aside for a particular patient
  (crossmatched) are actually transfused.
• when a patient does not need blood, it is good
  practice to get a T S but not a T C
• CT ratio is less than 21

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Maximum Surgical Blood Order Schedule (MSBOS)

• Is a guideline to order standard number of units
  of RBCs to be crossmatched for a specific
  surgical procedure, based on average use in the
  institution
• examples
• angioplasty TS
• aortic dissection TC 6

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Red cell Antigens ABO type

• present on RBCs, GI tract and vascular
  endothelium
• three alleles A, B, O, the A and B alleles code
  for glycosyltransferases
• specificity of the antigen is in its terminal
  sugar
• galactosamine for A
• galactose for B

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ABO type continued

• Pt Cells Pt Serum
• vs vs
• anti -A anti-B A cells B cells
• A 0 0 40
• B 0 0 11
• AB 0 0 4
• 0 0 0 45

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Rh Type

• Five important antigens of the Rh system are D,
  C, E, c, and e
• These antigens are product of two genes RHD and
  RHCE located on chromosome 1p36
• These one set of three D/d C/c and E/e is
  inherited from each parent
• example father CDe and mother cde then the
  genotype is CcDdee and the phenotype is CcDe

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Rh type

• Rh blood group antigens are present only on RBCs
• Rh positive means that the D antigen is present
  (85 on the population)
• Rh negative means that the D antigen is absent
  (15 of the population)
• the D antigen is highly immunogenic
• More than 80 of D negative persons receiving D
  positive blood are expected to develop anti-D

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Hemolytic Disease of the Newborn(HDN)

• D antigen is the most important cause of HDN
• mother is D neg, father is D pos and fetus is D
  positive
• fetus D positive RBCs enter mothers
  circulation and mother makes anti-D of IgG type
  which crosses the placenta
• first pregnancy not affected
• Maternal IgG crosses the placenta and affects the
  second D positive pregnancy
• anti-D formation in mother prevented with Rhogam

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Other Blood Group Systems

• clinically significant blood group systems are
  Kell (K), Kidd (Jk), Duffy (Fy) and Rh (E,e,C,c)
  systems.
• antibodies are made by people who lack the
  antigen on their RBCs
• and have been exposed to RBCs containing the
  antigen

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Other Blood Group Systems

• The following are not clinically significant
• I I
• Le Lewis love
• M my
• N new
• H honda
• P prelude

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Blood Used on Emergency Basis

• Blood used on Emergency Basis
• for a patient that is bleeding out
• and the blood type is unknown
• group O, Rh negative, uncrossmatched
• recipient may have an unexpected antibody
• after 5 min use ABO and Rh type specific blood

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Whole Blood

• 450 ml of whole blood with 63 ml of anticoagulant
• need for oxygen carrying capacity and volume
  replacement
• no viable platelets or WBC
• decreased labile coagulation factors (Factor V
  and VIII)
• Not available since it is not efficient
  utilization of blood

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Packed Red Blood Cells (PRBCs)

• 200-250 ml of RBCs and 50 ml of plasma
• Hematocrit 55-70 depending on anticoagulant
• shelf life 35 to 42 days depending on the
  anticoagulant
• treatment of symptomatic anemia where oxygen
  carrying capacity is needed

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Leukocyte Reduced RBCs

• RBCs with 99.99 of WBCs removed by leukocyte
  reduction filter
• prevents repeated nonhemolytic febrile
  transfusion reactions
• reduces immunosuppression of recipient by donor
  WBC
• decreases post-operative surgical infections due
  to reduced immunosuppression

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Leukocyte Reduced RBCs continued

• prevents or delays HLA alloimmunization
• identical to CMV seronegative blood
• does not prevent graft versus host disease, only
  gamma irradiation prevents graft versus host
  disease

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Indications for Leukocyte Reduced RBC continued

• after second nonhemolytic febrile transfusion
  reaction
• newly diagnosed leukemics
• long term multiple transfused patients
• sickle cell disease
• aplastic anemia
• thalassemia

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Frozen RBCs

• store RBCs for up to 10 years at -70C in glycerol
• glycerol is a cryopreservative solution
• used for
• rare blood types for patients with multiple
  antibodies
• autologous blood for a postponed operation

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(Gamma) Irradiated RBCs

• RBCs and platelets are exposed to gamma
  irradiation at 2500 rads for 4.5 minutes
• this inactivates the T lymphocytes in the donor
  unit and prevents graft versus host disease in an
  immunocompromised recipient

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Indications for Gamma Irradiated RBCs

• bone marrow transplant recipients
• congenital immunodeficiency syndromes
• intrauterine transfusions
• transfusions from all blood relatives
• Hodgkins disease
• WBC products (to neutropenic patient)
• (never Stem Cells)

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Plateletpheresis

• donated by a single donor
• 3.0 x 10 E11 platelets plus 300 ml of plasma,
  expires after 5 days
• raises the platelet count 30,000
• used for all platelet transfusions until less
  than 10,000 platelet increase

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Pooled Platelets

• are prepared from the platelet portion of 6 whole
  blood units plus 300 ml of plasma (potential for
  6 infectious disease exposures) expires after 5
  days
• 6 X 5 X 10 E10 3.0 x 10 E 11 platelets
• 6 x 5000 rise /RD plt 30,000
• transfuse the patient with platelets from many
  donors to see which platelets will raise the
  platelet count

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Indications for Platelets

• low platelet count or functional abnormality
• major bleed, major surgery gt100,000
• minor bleed, minor procedure gt50,000
• prevent spontaneous bleed gt 10,000

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Low Post-transfusion Increment to Platelets

• 1 hour post (platelet recovery) poor
• platelet alloantibodies
• platelet autoantibodies
• hepatosplenomegaly
• 24 hour post (platelet survival) poor
• infection bleeding
• DIC fever

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Fresh Frozen Plasma (FFP)

• 200-250 ml of plasma frozen at -18C within 8
  hours of collection
• no platelets are present
• contains all coagulation factors
• an unconcentrated source of fibrinogen
• use Cryo to correct a low fibrinogen level
• needs 20-30 min lead time to thaw prior to use

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FFP Continued

• used in patients with multiple coagulation factor
  deficiencies
• liver disease
• DIC
• massive transfusion
• indicated when PT/PTT are gt17/55 sec
• not used if non bleeding or for volume replacement

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Cryoprecipitate (Cryo)

• a white precipitate that forms when FFP at -18C
  is thawed to 4C
• volume is 10 to 15 ml
• adult dose is 10 to 20 pooled units
• 30 minutes is needed for thawing and pooling

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Cryoprecipitate continued

• Cryoprecipitate can be used for the replacement
  of all of the following
• vWF vWD
• Factor VIII Hemoplilia A
• Factor XIII Factor XIII def
• Fibrinogen dec. fibrinogen
• head injury, massive bleed, trauma,

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Complications of Blood Transfusion

• Immediate Delayed
• HTR GVHD
• FNTR PTP
• TRALI Iron
  overload
• Bacterial
  Infectious
• contamination diseases
• Allergic, Anaphylaxis Alloimmunization

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Transfusion Transmitted Disease (TTD)

• HBV 1 in 63,000
• HCV 1 in 103,000
• HTLV-I 1 in 641,000
• HTLV-II 1 in 641,000
• HIV-1 1 in 587,000
• HIV-2 lt 1 in 1,000,000

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Acute Hemolytic Transfusion Reaction

• a clerical error (wrong specimen, wrong patient)
• 1 in 6,000 to 25,000 transfusions
• back pain, chest pain, fever, red urine,
  oliguria, shock, DIC, death in 1 in 4
• stop the transfusion

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Work up of An AHTR

• start normal saline
• treat patient symptomatically
• send blood bag and tubing to culture
• send red top and purple top tubes
• urine specimen for hemoglobinuria
• DAT is positive

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Non Hemolytic Febrile Transfusion Reaction

• NHFTR (1100)
• Recipient has WBC antibodies to Donor WBCs
  contained within RBCs and Plateletpheresis
  products
• DAT is negative
• rise in temperature by 2F or 1C
• other causes for fever are eliminated

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Allergic (Urticarial) Transfusion Reaction

• Recipient has antibodies to the Donors plasma
  proteins (1 in 1000)
• offending protein is not identified
• urticaria, itching, flushing, wheezing
• this is the only transfusion reaction where the
  blood that is hanging can be restarted after
  treatment with Benadryl
• if symptoms continue then STOP

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Anaphlyactic Transfusion Reaction

• anaphylactic reaction (1 in 150,000)
• 1 in 700-900 people never made IgA
• occurs when exposed to normal blood products
  which contain IgA
• bronchospasm, vomiting and diarrhea and vascular
  collapse
• treat with Epinepherine, Solu-Medrol,

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Circulatory Overload

• marginal cardiovascular status
• given blood components too rapidly
• develops acute shortness of breath, heart
  failure, edema (1 10,000)
• systolic BP increases 50 mm
• infuse slowly, not to exceed 4 hours
• split the unit of RBC and give half

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Transfusion Related Acute Leukocyte Lung Injury

• TRALI reaction (110,000)
• Donor plasma contains WBC antibodies that when
  transfused to the recipient cause agglutination
  of recipients WBC in the pulmonary capillary
  beds
• Chest X ray looks like ARDS
• Donor removed from donating blood

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Sepsis from Bacterial Comtamination

• Platelets
• skin contaminants most common cause
• plateletpheresis 1 in 5000
• pooled platelets 1 in 1000
• RBC
• Sepsis from RBC due to Yersinia, Enterics or
  Gram Positive 1 in 3,000,000

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Thanks