1. Blood Transfusion Review
Salwa Hindawi
Medical Director of Blood Transfusion Services
KAUH
6th year Medical Student

2. 6th year Medical Student
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
6th year Medical Student

3. 6th year Medical Student
Blood Donation
WB every 8 weeks, Hct > 38%
Plateletpheresis every 3 days or 24 times per year, Hct > 38%
Autologous Blood
WB every 3 days
up to 3 days prior to surgery
Hct > 33%
6th year Medical Student

4. 6th year Medical Student
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
6th year Medical Student

5. 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
6th year Medical Student

6. Indirect Antiglobulin Test (IAT)
detects free antibodies in the serum
the IAT test is performed during the antibody screen and antibody identification
6th year Medical Student

7. 6th year Medical Student
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
6th year Medical Student

8. 6th year Medical Student
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
6th year Medical Student

9. 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
6th year Medical Student

10. 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
6th year Medical Student

11. 6th year Medical Student
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
6th year Medical Student

12. Crossmatch to Transfusion ratio (C:T 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
C:T ratio is less than 2:1
6th year Medical Student

13. 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 T&S
aortic dissection T&C 6
6th year Medical Student

14. 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
6th year Medical Student

15. 6th year Medical Student
ABO type continued
Pt Cells Pt Serum
vs vs
anti -A anti-B A cells B cells
A %
B %
AB % %
6th year Medical Student

16. 6th year Medical Student
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
6th year Medical Student

17. 6th year Medical Student
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
6th year Medical Student

18. 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 mother’s 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
6th year Medical Student

19. 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
6th year Medical Student

20. Other Blood Group Systems
The following are not clinically significant:
I I
Le Lewis love
M my
N new
H honda
P prelude
6th year Medical Student

21. 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
6th year Medical Student

22. 6th year Medical Student
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
6th year Medical Student

23. Packed Red Blood Cells (PRBCs)
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
6th year Medical Student

24. 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
6th year Medical Student

25. 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
6th year Medical Student

26. 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
6th year Medical Student

27. 6th year Medical Student
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
6th year Medical Student

28. (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
6th year Medical Student

29. Indications for Gamma Irradiated RBCs
bone marrow transplant recipients
congenital immunodeficiency syndromes
intrauterine transfusions
transfusions from all blood relatives
Hodgkin’s disease
WBC products (to neutropenic patient)
(never Stem Cells)
6th year Medical Student

30. 6th year Medical Student
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
6th year Medical Student

31. 6th year Medical Student
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
6th year Medical Student

32. Indications for Platelets
low platelet count or functional abnormality
major bleed, major surgery >100,000
minor bleed, minor procedure >50,000
prevent spontaneous bleed > 10,000
6th year Medical Student

33. 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
6th year Medical Student

34. Fresh Frozen Plasma (FFP)
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 min lead time to thaw prior to use
6th year Medical Student

35. 6th year Medical Student
FFP Continued
used in patients with multiple coagulation factor deficiencies:
liver disease
DIC
massive transfusion
indicated when PT/PTT are >17/55 sec
not used if non bleeding or for volume replacement
6th year Medical Student

36. 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
6th year Medical Student

37. 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,
6th year Medical Student

38. Complications of Blood Transfusion
Immediate Delayed
HTR GVHD
FNTR PTP
TRALI Iron overload
Bacterial Infectious
contamination diseases
Allergic, Anaphylaxis Alloimmunization
6th year Medical Student

39. 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 < 1 in 1,000,000
6th year Medical Student

40. 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
6th year Medical Student

41. 6th year Medical Student
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
6th year Medical Student

42. Non Hemolytic Febrile Transfusion Reaction
NHFTR (1:100)
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
6th year Medical Student

43. Allergic (Urticarial) Transfusion Reaction
Recipient has antibodies to the Donor’s 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
6th year Medical Student

44. Anaphlyactic Transfusion Reaction
anaphylactic reaction (1 in 150,000)
1 in 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,
6th year Medical Student

45. 6th year Medical Student
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
6th year Medical Student

46. Transfusion Related Acute Leukocyte Lung Injury
TRALI reaction (1:10,000)
Donor plasma contains WBC antibodies that when transfused to the recipient cause agglutination of recipient’s WBC in the pulmonary capillary beds
Chest X ray looks like ARDS
Donor removed from donating blood
6th year Medical Student

47. 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
6th year Medical Student

48. 6th year Medical Student
Thanks
6th year Medical Student