Salwa Hindawi
Assistant Professor in Haematology
Medical Director of Blood Transfusion Services
At the end of this presentation the students
Will be able to have a clear idea about transfusion chain including blood donation and component process, trigger and indication of blood
components.
Define ABO blood grouping and selection criteria
for blood grouping.
* Richard Lower : Animal to animal transfusion ( 1666 ) .
* Jean Denys : Animal to human transfusion ( 1667 ).
* James Blundell :Human to human
* Landsteiner: Blood group system (1901)
* Ottenberg: X-Match test (1913)
To Start What is Blood?
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
Donor Patient
Transfusion Chain
Paid Directed, replacement Volunteers
WB every 8 weeks, Hct > 38%
Plateletpheresis every 3 days or 24 times per year, Hct > 38%
Autologous Blood
◦ WB every 3 days (twice/week)
◦ up to 3 days prior to surgery
◦ Hct > 33%
Is Important
To Be Sure That The Donor Is Fit To Donate The Required Amount Of Blood
Blood Donation Will Not Harm The Donor
The Donated Blood Should Be Safe And Free
From Transfusion Transmitted Infections TTI
Donor Selection
I. Interview
II. Questionnaires
III. Physical examination
Donor safety
Patient safety
Single Donation Testing
Different countries screen for different organisms.
Each country has to set its own policies for screening of donors.
i. Serological screening
ii. Microbiological screening
HIV I & II (Ag-Ab), HBV, HCV, Syphilis HTLV-I & II, HBcAb
NAT for HIV, HBV, HCV
Special donors for CMV
Confirmatory tests
Any reactive donation should repeat testing in duplicate. If any of the repeated tests is reactive, a sample should be send to a reference laboratory and the donation will be destroyed by autoclaving or used for batch validation or quality control
purposes.
Sore throat or cold symptoms.
Blood transfusion within the last 12 months Recent surgery
Taking antibiotics
Travel to malarial areas Headaches or migraine Acupuncture
Pregnancy Ear piercing Dental abscess
Recent asthma attack
IV drug abusers
Homosexuals
Prostitutes
Haemophiliacs
Person with AIDs or who are HIV positive
Sexual contacts of the above
Hepatitis B (HBV)
Hepatitis C (HCV)
Whole blood
Platelets rich plasma
1stcentrifugation
Platelets concentrate
Whole blood
Whole blood
2nd centrifugation
Fresh plasma
FFP for clinical use
FFP for fractionation
Optimal additive solution
Red cells in OAS
Cryoprecipitate
Red Cell concentrate
Whole blood
Packed RBCs
Platelets
Single donor platelets (Apheresis)
Fresh Frozen Plasma (FFP)
Cryoprecipitate
Use and shelf life
Whole blood 510ml (45)
Acute massive blood loss
35 days 4C + 2C -
PRBC
280ml
Chronic anaemia, renal disease, Sickle cell
anemia, Haemorrhage
35-42days 4C + 2C
Platelets
50ml (single) Pooled 200m l)
DIC
thrombocytopenia
5 days
22C.Gentleagitation
FFP
Not a volume expander 200-300ml
Thromotic
thrombocytopenic purpura.
Warfarin overdose
12 months -30C
Four blood groups: A, B, O, or AB
Almost all serum contains antibodies to ABO antigens it lacks
Antibodies are crucial to safe transfusion
type A
type B type O
type AB
Red blood cell antigens
A antigen A and B antigen
B antigen H antigen
(no A or B antigen)
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
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
Type and Screen (T & S):
(Done for low probability of transfusion)
◦ ABO and Rh type
◦ Antibody screen
◦ Antibody identification
Type and Crossmatch (T & C)
(Done for high probability of transfusion)
above steps plus Crossmatch
ABO grouping is the single most important
serological test performed on pre-transfusion
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%
Patient ABO Type
Antibody (Serum)
RBCs or Granulocyt
es
Plasma- Containing Componen
ts*
Whole Blood
O (45%)
Anti-A
andAnti-B O A, B, AB, O O
A
(40%) Anti-B A, O A, AB A
B
(11%) Anti-A B, O B, AB B
AB
(4%) None A, B, AB, O AB AB
ABO Selection of Blood
Components
that antibody screening should be performed in all pre-transfusion testing.
As a minimum the following antigens must be expressed within the screening cell set:
C, c, D, E, e, K, k, Fya, Fyb, Jka, Jkb, S, s, M, N,
Lea
after the Ab screening 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
RBC Agglutination
donor RBCs (unit of blood) are tested with recipient serum
to detect unexpected recipient antibodies
this checks to see if the transfusion is
compatible
The lowest threshold for transfusion of components are:
Hb level of 6-7g/dl.
FFP threshold PT & PTT 1.5 times the upper limit of the normal range.
Platelet threshold of:
10 000/µl- 20 000/µl for prophylactic transfusion.
Consider: Clinical judgment
Triggers of Component
Transfusion
Invasive or surgical procedures:
20 000/µl for BMA and Biopsy
50 000/µl for surgery, massive transfusion, Liver cirrhosis.
100 000/µl for surgery to brain or eye .
American Society of clinical Oncology guidline,1996&2001.
Williamson LM. Transfusion Trigger in the UK. Vox sang 2002.
AABB Technical Manual 14th ed, 2002.
Avoid blood transfusion
Transfusion is only one part of the patient’s management.
Prevention and early diagnosis and treatment of Anemia & underlying condition
Use of alternative to transfusion.
eg. IV fluids
Good anesthetic and surgical
management to minimized blood loss.
–
Prescribing should be based on
national guidelines on the clinical use of blood taking individual patient
needs into account.
–
Hb level should not be the sole deciding Factor Clinical
evaluation is important
–
Consent form to be obtained from the patient before transfusion.
–
The clinician should record the reason for transfusion clearly.
–
A trained person should monitor the
transfused patient and if any adverse effects
occur respond immediately.
CRYSTALLOID SOLUTIONS
COLLOID SLOUTIONS
DRUGS
BIOLOGIC RESPONSE MODIFIERS
BLOOD SUBSTITUTES
Guidelines for blood
component therapy
Indications NB: Hb should not be the sole deciding factor for transfusion.
Haemoglobin (Hb) trigger for transfusion
If there are signs or symptoms of impaired oxygen transport
Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available e.g. sickle cell disease or iron deficiency anemia
< 7 g/dL
Preoperative and for surgery associated with major blood loss.
< 7 – 8 g/dL
In a patient on chronic transfusion regimen or during marrow suppressive therapy.
May be appropriate to control anaemia-related symptoms.
< 9 g/dL
Not likely to be appropriate unless there are specific indications.
Acute blood loss >30-40% of total blood volume.
< 10 g/dL
Guidelines for red blood cells
Indications Platelet Count
trigger for transfusion
As prophylaxis in bone marrow failure.
< 10 x 109/L
Bone marrow failure in presence of additional risk factors: fever, antibiotics, evidence of systemic haemostatic failure.
< 20 x 109/L
Massive haemorrhage or transfusion.
In patients undergoing surgery or invasive procedures.
Diffuse microvascular bleeding-DIC
< 50 x 109/L
Brain or eye surgery.
< 100 x 109/L
Appropriate when thrombocytopenia is considered a major contributory factor.
Any Bleeding Patient
In inherited or acquired qualitative platelete function disorders, depending on clinical features & setting.
Any platelet count
Indications FFP trigger for
transfusion
Multiple coagulation deficiencies associated with acute DIC.
Inherited deficiencies of coagulation inhibitors in patients undergoing high- risk procedures where a specific factor concentrate is unavailable.
Thrombotic thrombocytopenia purpura (plasma exchange is preferred)
Replacement of single factor deficiencies where a specific or combined factor concentrates is unavailable.
Immediate reversal of warfarin effect in the presence or potentially life- threatening bleeding when used in addition to Vitamin K & / or Factor Concentrate (Prothrombin concentrate)
The presence of bleeding and abnormal coagulation parameters following massive transfusion or cardiac bypass surgery or in patients with liver disease
PT & PTT are more than 1.5 times the upper limit of normal range
Indications Cryoprecipitate
trigger for transfusion
Congenital or acquired fibrinogen deficiency including DIC.
Hemophilia A, von Willebrand disease (if the concentrate is not available).
Fibrinogen< 1gm/L
1. transfusion dependent patients
2. Bone marrow transplant candidates – either autologous / peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants
3. may be for Patients undergoing intensive chemotherapy regimens 4. Previous repeated febrile reactions to red blood cells
Guidelines for routine blood leucodepletion
1.Intrauterine transfusion (IUT) and neonates received IUT.
2.One week prior to stem cell collection, and for 12 months post autografting or allografting.
3.Hodgkin’s disease
4.Treatment with purine analogues (fludarabine, 2-CdA, deoxycofomycin)
5.Aplastic anaemia within 6 months of ATG treatment
6.Products obtained from close relatives or HLA matched donors.
7.Immunodeficiency patients: congenital or acquired Guidelines for
blood Irradiation (to prevent
TAGVHD)
Transfusion Reactions
* Hemolysis
• Febrile non hemolytic reaction.
• TRALI
* Anaphylaxis
*Urticaria
*Non-cardiac
pulmonary edema .
RBC Incompatibility Donor
‘s Granulocytes Ab in donor plasma Ab to IgA
Ab to plasma proteins Ab to leukocytes or
compliment activation
* Marked fever &
Shock
* Congestive Heart Failure
* Haemolysis
Bacterial
contamination Volume Overload
Physical Destruction e.g. Freezing or
Overheating
* Haemolysis
* Graft Vs Host disease
* Post-Transfusion Purpura
* Alloimmunization
Anamnestic
Antibody Reaction
Engraftment of
Functional Transfused Lymphocytes
Ant platelet Abs
Exposure to Antigens of Donor Origins
