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Blood constituents available for clinical use are:
1. Whole blood
2. Blood components:
a- Red cells: Packed RBCs
- Leukocyte poor
- Frozen RBCs
b- Platelets concentrate.
c- Fresh frozen plasma FFP.
d- Cryoprecipitate.
3. Plasma products:
a- Human albumin solution.
b- Coagulation factor concentrate.
c- Immunoglobulins.
Preparations for transfusion:
To avoid the danger and the risks of a mismatched blood transfusion,
it is important and necessary to go the following steps:
1- Patient blood grouping ABO antigens (Ag):
The frequencies of ABO and Rhesus blood groups vary from one
population to another.
I- Blood group A contains A Ag in RBCs and B antibody (Ab) in
plasma. It accounts about 40% of population.
II- Blood group B contains B Ag in RBCs and A Ab in plasma. It
accounts about 10% of population.
III- Blood group AB contains both A and B Antigens in RBCs and
containing no Abs, accounting about 5% of the population.
IV- Blood group O contains no Antigens but contains both A and B
antibodies in plasma. It accounts in about 45% of the population.
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2- Rhesus [D] Ag:
- 85% of the population are Rh +ve.
- Persons with blood group O negative are called universal donor.
3- Cross matching:
The donor cells are tested with the patient serum which is done in two
steps: I- Direct test. II- Indirect test.
4- Check name of the patient, file number, unit number., blood group
for both unit and patient and the expiry date of the unit, and be sure
of the result of virology screening.
5- Prepare the patient by inserting a new IV canula, preferably in a
large vein, the patient should be for close observation.
Whole blood transfusion
* Blood collected from the donor in sterile collecting system
containing 75 ml of anticoagulant solution:
I- ACD Acid Citrate Dextrose (3 weeks)
II- CPD Citrate Phosphate Dextrose (4 weeks)
III- CPD-Adenine Citrate Phosphate Dextrose Adenine (35days)
* 450 ml of blood are collected in the collecting bag
* It is stored in a refrigerator at 4ْ C
* It is a poor source of platelets and liable clotting factors
* It is not heat treated so it carries the risk of disease transmission
* Indications of blood transfusions:
1- Acute haemorrhagic and hypovolumic shock (severe burns, sever
traumatic incidents)
2- Major surgery with inevitable blood loss (cardiovascular)
3- Exchange transfusion in neonates (fresh whole blood)
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4- Patient with haemostatic defects (if other substitutes are not
available)
* Transfusion of 1 unit of whole blood will raise the HB% by about 1
gm, and the haematocrit By 3%.
* Red cells transfusion:
I- Packed red blood cells (PRBCs - plasma reduced): Prepared by
removing plasma from whole blood and the RBCs are suspended
in a special storage solution.
- Shelf life is 35 days when stored at 4 C.
- It is not heat treated so it carries the risk of disease transmission.
PRBCs alone are not sufficient for volume restoration, but they can be
combined with normal saline. The use of leukocyte-poor RBCs or
washed RBCs may prevent nonhemolytic transfusion reactions in
previously sensitized patients.
* Indications for packed RBCs transfusion are:
1- Haemorrhage.
2- Acute anemia.
3- Symptomatic chronic anemia.
4- Bone marrow failure.
- It cannot be given to neonates (very important).
II. Leukocytes depleted RBCs:
1- Prepared by filtering blood during extraction by bedside leukocyte
filter to remove WBCs.
- Indications:
1. It is actually rarely used.
2. Patients sensitized to HLA, granulocytes or platelet Ags.
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III. Frozen RBCs:
1. It’s a rare and expensive type that is only available in specialized
centers.
2. It has a longer shelf life once frozen.
3. If warmed the shelf life is only 24hrs.
4. It carries the risk of disease transmission.
5. Indicated in those with multiple Abs
IV. Phenotyped RBCs:
1. It should correspond as closely as possible to the recipient RBCs.
2. Indicated in patients. with multiple Abs.
Platelets transfusion:
1. Prepared from whole blood within few hours from its collections.
It can be either pooled platelets or a single unit.
2. 1 unit may contain 5-10 x 10 power 10 platelets 50-70ml of plasma.
3. it contain variable amount of clotting factor V and VIII
4. It is not heat treated so it carries the risk of disease transmission.
5. 1 unit of transfused platelets raises the platelet count by 5,000 -
10,000 /ml. * Shelf life is 4 – 6 days.(platelets in whole blood
have shelf life of few (< 24 hours only).
The necessity for platelet transfusion is based on both the platelet
count and the clinical condition. The risk of spontaneous hemorrhage
is high when platelet counts are below 1000\mm3 and is increased
when associated with trauma, ulcerations, or invasive procedures.
Indications of platelets transfusion:
1- Thrombocytopenia < 50,000.
2- Prophylactic in patient on chemotherapy and those with bone
marrow failure.
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3- Platelets dysfunction which may occur in liver failure or renal
failure.
4- Disseminated Intravascular Coagulation (DIC).
5- Following a massive blood transfusion.
Fresh Frozen Plasma FFP:
Fresh frozen plasma (FFP) consists of all the blood coagulation factors
(including labile factors V and VII) and is packaged in 2oo to 250 ml
units.
* Prepared by centrifugation of whole blood within 4-6 hours of
collection and frozen at – 30 to -40 ْ C, usually volume of 200 ml.
* Shelf life is 1 year.
* It is carrying the risk of disease transmission.
* It is a good source of all coagulation factors and plasma proteins.
* It has no platelets and a low level of fibrinogen.
* Indications of FFP are:
1. Antithrombin III deficiency.
2. Liver disease with abnormal coagulation factors. It should be
given with vitamin K injection.
3. Reversal of warfarin [ Coumarine ] action.
4. In DIC or massive blood transfusion for coagulation factor
replacement.
5. The deficient coagulation factors are II, V, VII, IX, X, XI, XIII
with bleeding or before an invasive procedure.
6. Other indications of FFP including: Haemolytic uraemic syndrome
and thrombotic Thrombocytopenic purpura. It is not used as a
volume expander or nutrient supplement.
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Cryoprecipitate:
1. Prepared from FFP (when it allowed to thaw at 4ْ C, white
gelatinous precipitate), and stored at – 40ْ C.
2. It is rich in fibrinogen, fibrinectin and factor VIII, Von Willebrand
factor.
3. Shelf life is 1 year.
4. Can be heat treated to inactivate viruses reducing the risk of
disease transmission.
* Indications of cryoprecipitate:
1. Factor VIII deficiency (Haemophilia A).
2. Von Willebrand disease.
3. Hypofibrinogenaemia ( massive blood transfusion).
4. DIC.
5. Renal and liver failure.
Plasma products:
Prepared from pooled human plasma and undergone a process of
sterilization under heat effects to reduce the risk of microbial and
viral infection.
a. Albumin solution:
* It can be 4.5 %, 20% salt poor solution.
* It contains no coagulation factors.
* It is heat treated, so it is free of the danger of disease transmission
* Stored at 4ْ C for several months
* Indications:
(A) For 4.5% albumin solution:
1- Hypoproteinaemia.
2- Burns.
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3 - Haemorrhage.
4- Shock.
(B) For 20% albumin solution:
1- Severe hypoproteinaemia.
2- Septicaemia G-ve.
3- severe liver disease or nephrotic syndrome.
4- Massive liver resection
b. Coagulation factors concentrate:
1. Factor VIII concentrate for haemophilia A.
2. Von Willebrand factor concentrate for Von Willebrand disease.
3. Factor IX concentrate:
This contains factors II, IX and X for treatment of bleeding
complications and treatment of oral anticoagulant overdose.
4. Fibrinogen:
- Prepared from plasma and stored in dried form
- In cases of DIC and afiberinogenaemia
- It carries the risk of disease transmission
c. Immunoglobulins (Ig):
* Specific Ig as: hepatitis B Ig or herpes zoster Ig.
* Non specific Ig: which is a group of Igs against many diseases
as hepatitis A, rubella and measles.
d. SAG-mannitol blood:
* Prepared by removing all plasma from blood and replacing it
with 100 ml of crystalloid solution containing: NaCl, adenine,
glucose anhydrous and mannitol.
* It allows good viability of the cells
* It contain no proteins
* In treatment of anemia
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Hazards of blood transfusion
I- Immune mediated transfusion reactions:
a- Allergic reactions:
1. Plasma protein associated reactions
2. Due to anti IgA Abs against serum proteins
3. Varying in severity from urticarial wheals, tachycardia, pruritus,
flushing, chills, dyspnoea, wheezing to anaphylactic shock,
bronchospasm and laryngeal spasm in severe cases.
* Treatment:
- Transfusion ? Stopped in severe cases.
- Antihistamines, subcutaneous adrenaline.
- Other supportive measures in severe cases.
b- Febrile reaction:
1. Due to Abs against leukocytes and platelets, or pyrogens in the
donor apparatus
2. Clinically: fever, tachycardia, flushing, and chills.
3. Fever can be the first manifestation of a more serious reaction
(septic reaction). So the patient should be evaluated promptly.
* Treatment:
1. +/- Stop blood transfusion.
2. Antipyretic treatment.
3. Leukocyte poor blood may be needed to prevent the reaction.
c- Haemolytic reaction (HR):
It can be immediate or delayed haemolytic reaction
1- Immediate haemolytic reaction:
A. It is usually due to ABO incompatibility which may be a result
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of faulty blood bank technique or due to Clerical error (wrong
patient or wrong unit).
B. When HR occurs complement activated which will cause
membrane lysis and intravascular haemolysis.
C. Clinically: fever, chills, chest pain, loin pain, hypotension,
nausea, flushing, dyspnoea, haemoglobinuria, bleeding tendency
and oliguria or anuria shock.
D. In severe cases e.g: DIC and acute renal failure (acute renal
tubular necrosis).
E. If the patient under general anasthesia: unusual profuse bleeding
and hypotension despite of adequate resuscitation should raise
suspicion of HR.
* Treatment of immediate HR:
1- Immediately stop the transfusion.
2- Close observation of patient urinary out put
3- Take sample for blood grouping from the patient and the blood
unit.
4- Start intravenous fluid (crystalloid).
5- Loop diuretic.
6- Alkalinization of urine by NaHCO3, to prevent precipitation of
haemoglobin in renal tubules.
7- In DIC +/- heparin injection
8- In severe cases, haemodialysis could be needed
2- Delayed haemolytic reaction:
* It occurs after 7-21 days of transfusion.
* Clinically: Triad of anaemia, fever and history of recent blood
transfusion.
* No specific treatment.
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II - Reaction of contaminated blood:
* Contamination may occur through improper collection technique
or instrument or storage or during the administration process, or if
blood warmed for few hours before transfusion
* The most common organism is staphylococci but gram –ve organism
contamination may occur producing severe reaction.
* Clinically:High temperature > 39C, flushing, headache, vomiting,
diarrhoea and hypotension that may end in septic shock.
* Contamination should be suspected if clots or foreign material seen
within the unit, gross haemolysis or changes in the colour of blood.
* Treatment: If contamination suspected:
1- Stop transfusion immediately.
2- Samples of donor unit and patient blood for aerobic and
anaerobic culture sensitivity
* Treatment of septicaemia:
1- Intravenous fluid.
2- Antibiotics.
3- Respiratory support.
4- +/- blood transfusion.
III- Thrombophlebitis:
* In superficial veins leading to thrombosis.
* Due to canulation and infusion.
IV- Air embolism:
* Very rarely occurs, when giving a set not well prepared and sucked
from its contained air, which can travel through the vein and acts
as an embolus.
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