1. Whole Blood Processed within 8 hours ) Packed red blood cells Fresh frozen plasma Platelets

2. Component preparation Principle - Differential centrifugation Principle - Differential centrifugation Red cells Red cells Packed cells Packed cells Red cells + additive Red cells + additive Plasma Plasma Bank plasma Bank plasma Fresh frozen Fresh frozen Cryo supernate Cryo supernate Platelets Platelets Platelet rich concentrate Platelet rich concentrate Platelet rich plasma Platelet rich plasma Cryoprecipitate Cryoprecipitate Plasma + Platelets Buffy RBC Whole blood

3. DEFINITIONS BLOOD PRODUCT = Any therapeutic substance prepared from human blood WHOLE BLOOD = Unseparated blood collected into an approved container containing an anticoagulant preservative solution BLOOD COMPONENT = 1. A constituent of blood, separated from whole blood such as Red cell concentrate Red cell concentrate Plasma Plasma Platelet concentrates Platelet concentrates 2. Plasma or platelets collected by apheresis 3. Cryoprecipitate prepared from fresh frozen plasma

4. Blood Components THE PRBC THE PRBC Storage Storage - 2 – 6 O C - 2 – 6 O C Unit of issue Unit of issue - 1 donation ( unit or pack ) - 1 donation ( unit or pack ) Administration Administration - ABO & Rh compatible - ABO & Rh compatible - Never add medication to a unit - Never add medication to a unit - Complete transfusion within 4 hrs of commencement - Complete transfusion within 4 hrs of commencement 1MemberMember

5. Dosage & Administration Dosage - 1 unit/10 kg body wt Adult dose is 4-8 units Administration - Preferably ABO & Rh group specific but not essential Other groups can be used

6. PLATELETS Platelet units can be either Platelet units can be either Random donor units Random donor units Apheresis units Apheresis units 1 random donor unit contains 55 x10 9 platelets 1 random donor unit contains 55 x10 9 platelets 1 apheresis unit contains 240x10 9 1 apheresis unit contains 240x10 9

7. Guidelines for Platelet Tx. Mild - 50,000-1,00,000/µl Tx - usually not required Moderate - 20,000-50,000/µl Tx-if symptomatic or has to undergo surgery/trauma Severe - < 20,000/µl Risk of bleeding - high Prophylactic Tx

8. Indications for platelet transfusion BLEEDING due to thrombocytopaenia BLEEDING due to thrombocytopaenia Due to platelet dysfunction Due to platelet dysfunction Prevention of spontaneous bleeding with counts < 20,000 Prevention of spontaneous bleeding with counts < 20,000

9. IMPORTANT PRECAUTIONS IMPORTANT PRECAUTIONS Stored at 20-24 Degree celcius. Stored at 20-24 Degree celcius. Constantly agitated Constantly agitated Only last for 5 days Only last for 5 days Infused in 30 mins Infused in 30 mins

10. Fresh Frozen plasma Fresh frozen plasma – labile & nonlabile clotting factors, albumin and immunoglobulin. Factor VIII ( 8 ) level at least 70 % of normal fresh plasma level Fresh frozen plasma – labile & nonlabile clotting factors, albumin and immunoglobulin. Factor VIII ( 8 ) level at least 70 % of normal fresh plasma level Storage Storage - 20 C for 1 yr, - 65 C for 7 yrs. - 20 C for 1 yr, - 65 C for 7 yrs. - Before use thawed at 37 o C

11. Fresh frozen plasma Fresh frozen plasmaIndications - Replacement of multiple coagulation factor deficiencies eg Liver disease Liver disease Anticoagulant overdose Anticoagulant overdose Depletion of coagulation factors in pts receiving large volume transfusions Depletion of coagulation factors in pts receiving large volume transfusions - DIC (disseminated intravascular coagulation)

12. FRESH FROZEN PLASMA Indication  Clinically significant deficiency of Factors II, V, X, XI  Replacement of multiple coagulation factor deficiencies :- factor deficiencies :- liver disease, warfarin treatment, liver disease, warfarin treatment, dilutional and consumption coagulopathy dilutional and consumption coagulopathyContraindication Volume expansion Volume expansion Immunoglobulin replacement Immunoglobulin replacement Nutritional support Nutritional support Wound healing Wound healing 12

13. FRESH FROZEN PLASMA Precaution Acute allergic reaction are common Acute allergic reaction are common Anaphylactic reaction may occur Anaphylactic reaction may occur Hypovolemia alone is not an indication for Hypovolemia alone is not an indication for use use Dosage - Initial dose of 15 - 20 ml / kg Administration Must be ABO compatible, Rh not required Must be ABO compatible, Rh not required Infuse as soon as possible after thawing Infuse as soon as possible after thawing ( within 6 hrs ) ( within 6 hrs ) using standard blood administration set using standard blood administration set 30/11/49 MD-3-4913

14. FFP Fresh Frozen Plasma Fresh Frozen Plasma Plasma collected from single donor units or by apheresis Plasma collected from single donor units or by apheresis Frozen within 8 hours of collection Frozen within 8 hours of collection -40 o C -40 o C Can last for a year Can last for a year

15. Dosage & Administration for FFP Dosage - 10-15 ml/Kg(Approx 2-3 bags for an adult) Administration - Thawed at +37 o C before transfusion ABO compatible Group AB plasma can be used for all patient

16. Do`s and Dont`s In Blood and Blood Components

17. Risk Benefit Analysis benefit > risk risk > benefit Hb gm/dl 4 5 6 7 8 9 10 11 12 13 14 why not transfuse why transfuse individual patient factors decide transfusion trigger

18. 18 Blood/ Start infusion Complete infusion blood product Whole blood/within 30 min. of within 4 hour red cells removing pack (less in high from ambient temperature) refrigerator Platelet immediatelywithin 20 min concentrates FFP within 30 min within 20 min Time Limits for Infusion

19. TRANSFUSION REACTIONS TRANSFUSION REACTIONS @RBC’s ! Nonhemolytic 1-5 % transfusions Nonhemolytic 1-5 % transfusions Causes -Physical or chemical destruction of Causes -Physical or chemical destruction of blood: freezing, heating, hemolytic drug blood: freezing, heating, hemolytic drug -solution added to blood -solution added to blood -Bacterial contamination -Bacterial contamination : fever, chills, urticaria : fever, chills, urticaria Slow transfusion, diphenhydramine, antipyretic for fever Slow transfusion, diphenhydramine, antipyretic for fever Hemolytic Hemolytic Immediate: ABO incompatibility (1/ 12-33,000) with fatality (1/ 500- 800,000) Immediate: ABO incompatibility (1/ 12-33,000) with fatality (1/ 500- 800,000) Majority are group O patients receiving type A, B or AB blood Majority are group O patients receiving type A, B or AB blood Complement activation, RBC lysis, free Hb (+ direct Coombs Ab test) Complement activation, RBC lysis, free Hb (+ direct Coombs Ab test)

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

21. Anesthesia: hypotension, urticaria, abnormal bleeding Anesthesia: hypotension, urticaria, abnormal bleeding Stop infusion, blood and urine to blood bank, coagulation screen (urine/plasma Hb, haptoglobin) Stop infusion, blood and urine to blood bank, coagulation screen (urine/plasma Hb, haptoglobin) Fluid therapy and osmotic diuresis Fluid therapy and osmotic diuresis Alkalinization of urine (increase solubility of Hb degradation products) Alkalinization of urine (increase solubility of Hb degradation products) Correct bleeding, Rx. DIC Correct bleeding, Rx. DIC

22. @WBC’s! @WBC’s! Europe: All products leukodepleted Europe: All products leukodepleted USA: Initial FDA recommendation now reversed pending objective data (NOT  length of stay for  expense) USA: Initial FDA recommendation now reversed pending objective data (NOT  length of stay for  expense) Febrile reactions Febrile reactions Recipient Ab reacts with donor Ag, stimulates pyrogens (1-2 % transfusions) Recipient Ab reacts with donor Ag, stimulates pyrogens (1-2 % transfusions) 20 - 30% of platelet transfusions 20 - 30% of platelet transfusions Slow transfusion, antipyretic, meperidine for shivering Slow transfusion, antipyretic, meperidine for shivering

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

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

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

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

27. 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

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

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

30. NANB and Hepatitis C NANB and Hepatitis C Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/ 125,000 with 3rd generation HCV Ab/ HVC RNA tests Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/ 125,000 with 3rd generation HCV Ab/ HVC RNA tests Window 4 weeks Window 4 weeks 70 % patients become chronic carriers, 10-20 % develop cirrhosis 70 % patients become chronic carriers, 10-20 % develop cirrhosis

31. HIV Current risk 1/ 450- 660,000 (95) Current risk 1/ 450- 660,000 (95) With current screening (Abs to HIV I, II and p24 Ag), window 6-8 weeks (third generation ELISA tests in Europe) 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  sero -ve window to < 16 days

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

33. II. Bacterial II. Bacterial Contamination unlikely in products stored for > 72 hours at 1-6 0 C Contamination unlikely in products stored for > 72 hours at 1-6 0 C gram –ve, gram +ve bacteria gram –ve, gram +ve bacteria most frequent – Yersinia enterocolitica most frequent – Yersinia enterocolitica Produced endotoxin Produced endotoxin Platelets stored at room temperature for 5 days, with infection rate of 0.25% Platelets stored at room temperature for 5 days, with infection rate of 0.25% III. Protozoal III. Protozoal Trypanosoma cruzi (Chaga’s disease) Trypanosoma cruzi (Chaga’s disease) Malaria Malaria Toxoplasmosis Toxoplasmosis Leishmaniasis Leishmaniasis

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

35. METABOLIC COMPLICATIONS Citrate toxicity Citrate (3G/ unit WB) binds Ca 2+ / Mg + Citrate (3G/ unit WB) binds Ca 2+ / Mg + Metabolized liver, mobilization bone stores Metabolized liver, mobilization bone stores Hypocalcemia ONLY if > 1 unit/ 5 min or hepatic dysfunction Hypocalcemia ONLY if > 1 unit/ 5 min or hepatic dysfunction Hypotension more likely due to  cardiac output/ perfusion than  calcium (except neonates) Hypotension more likely due to  cardiac output/ perfusion than  calcium (except neonates) Worse with hypothermia/ hepatic dysfunction Worse with hypothermia/ hepatic dysfunction