MEDICAL TECHNOLOGY ASSESSMENT PROGRAM 2

IMMUNOHEMATOLOGY
LECTURE 12: BLOOD TRANSFUSION AND
COMPONENT THERAPY

Menissa S. Acierto, RMT, MEd

BLOOD TRANSFUSION
Taking of blood or blood-based products from one individual and inserting them into
the circulatory system of another
Done in cases of massive blood loss due to trauma, surgery, shock and where the cell
producing mechanism fails
Used primarily to treat two conditions:
Inadequate oxygen-carrying capacity because of anemia or blood loss
Insufficient coagulation proteins to provide adequate hemostasis
Autologous transfusion – refer to those transfusions in which the blood donor and
recipient are the same
Allogenic transfusion – refer to blood transfused to someone other than the donor
COMPONENT THERAPY
Transfusion of the specific component needed by the patient or recipient
With this, we can treat several patients with the blood from one donor, giving optimal
use of every donation of blood
BLOOD COMPONENT PREPARATION AND STORAGE
Each unit of blood collected may be transfused as whole blood or split into
components
The components may be transfused to different recipient as the need arises
Dividing a unit of whole blood into component is a common practice that optimizes
the use of blood as a therapeutic material
COMPONENTS AVAILABLE FOR TRANSFUSION AND
POTENTIAL RECIPIENTS
COMPONENTS AVAILABLE FOR TRANSFUSION AND
POTENTIAL RECIPIENTS
COMPONENT PREPARATION FROM A SINGLE UNIT OF
BLOOD (PROCEDURE I)
COMPONENT PREPARATION FROM A SINGLE UNIT OF
BLOOD (PROCEDURE II)
STORAGE TIME AND TEMPERATURE FOR COMPONENTS
STORAGE TIME AND TEMPERATURE FOR COMPONENTS
BLOOD COMPONENTS AND PLASMA DERIVATIVES
Blood components refer to a product separated from a single unit of whole blood
Oxygen Carrying Components
Whole blood
Red cell concentrate
Leukocyte poor blood
Washed PRBC
Frozen RBC
Platelet products
Platelet rich plasma
Platelet concentrate
Plasma product
Fresh frozen plasma
Frozen plasma
Cryoprecipitate
Stored plasma
WBC
Granulocyte concentrate
BLOOD COMPONENTS AND PLASMA DERIVATIVES
Plasma Derived components (Plasma derivatives are separated from a large volume of pooled plasma by
fractionation process)
Coagulation factor concentrate
Factor VIII concentrate
Factor IX complex concentrate and others
Oncotic agents
Albumin
Plasma protein fraction
Immune serum globulin
Hepatitis B Immune Globulin (HBIg)
Varicella zoster Immune globulin (VZIg)
Rh immune globulin (RhIg)
Tetanus Immune Globulin (TIg)
WHOLE BLOOD
Composition
Donor blood mixed with the anticoagulant and preservative solution (diluted in the
proportion of 8 parts of blood to one part anticoagulant)
Anticoagulant and preservative
Citrate in the anticoagulant chelates ionized calcium preventing activation of the
coagulation system
Glucose, adenine and phosphate (if present) serve as substrates for RBC metabolism
during storage
Indication
Whole blood is used to replace the loss of both RBC mass and plasma volume in
actively bleeding patients
WHOLE BLOOD
Contraindication of whole blood
Definite contraindication is severe chronic anemia
Patients with severe chronic anemia have reduced amount of RBC but are
compensated by increasing their plasma volume to restore the total blood volume
Patients with severe chronic anemia do not need plasma in whole blood and the
unneeded plasma may develop pulmonary edema and heart failure.
For a typical 70 kg (155 lb) human, each unit of whole blood transfused can result to:
3 to 5 % increase in hematocrit
1 to 1.5 g/dl of hemoglobin
RED BLOOD CELLS
Preparation
RBC are prepared by removing approximately 80% of the plasma from a unit of whole blood (AABB
suggests 230 to 256g [225 to 250 ml]) of plasma be removed from WB
The average hematocrit is between 65 and 80% (not to exceed 80%)
RBC is prepared anytime during the normal dating period by centrifugation or sedimentation. PRBC
are preserved by additive solutions
Indication
RBC is indicated for increasing the RBC mass in patients who require increased oxygen-carrying
capacity
The decreased RBC mass may be caused by:
Decreased bone marrow production (leukemia or aplastic anemia)
Decreased RBC survival (hemolytic anemia)
Surgical or traumatic bleeding
RED BLOOD CELLS
Advantages of RBC over whole blood
Equal O2 capacity in half volume of WB
Significant reduction in the level of isoagglutinins (anti-A and anti-B) thus facilitating the safe
transfusion of Group O cells to non-Group O recipients
Significant reduction in the levels of acid, citrate, and potassium load in patients with cardiac, renal or
liver disease
Need for RBC transfusion
There are no set hemoglobin levels that indicate a need for transfusion
Consensus committees suggest trigger values of hemoglobin less than 6.0 g/dl in the absence of
disease and between 8 and 10 g/dl with disease
Contraindication of RBC
RBC is contraindicated in patients who are well compensated for the anemia such as those with
chronic renal failure
RED BLOOD CELLS
In a typical 70 kg (155 lb) human, each unit of transfused RBC is expected to increase
Hemoglobin level: 1-1.5 g/dl
Hematocrit : 3-5%
RBC aliquots
Aliquoted RBC is the product most often transfused during neonatal period for the
treatment of anemia caused by spontaneous fetomaternal hemorrhage, obstetric
accidents and internal hemorrhage
Irradiation
Done on RBC and platelets to reduce the risk of transfusion associated graft versus
host (TA-GVH) disease in patients receiving allogenic bone marrow transplants (BMT)
RED BLOOD CELLS
Whole blood vs. PRBC

Whole blood vs. PRBC

RED BLOOD CELLS
PRBC has a high hematocrit, hence very viscous and slow rate of infusion.
To lower the viscosity and increase rate of infusion, it is added with saline solution.
Avoid calcium-containing fluid such as Ringer’s lactate solution because it can cause
clotting.
Glucose is also avoided because it can cause clumping
LEUKOCYTE-REDUCED RBC
The average unit of RBC contains approximately 2x109 leucocytes
The leucocytes in the units of RBC must be reduced, because donor leucocytes can cause:
Febrile non-hemolytic transfusion reactions
HLA Alloimmunization
Transfusion-related acute lung injury
Transfusion-related graft-versus-host disease
Transfusion-related immune suppression
Donor leucocytes may harbor pathogens such as
CMV
EBV
HIV
HTLV
LEUKOCYTE-REDUCED RBC
Most of the white cells can be removed by discarding the buffy coat after inverted
centrifugation
A reduced leucocyte content to less than 5x108 prevents most febrile non-hemolytic
transfusion reactions.
With the use of third-generation leucocyte reduction filter, the leucocyte content may
be less than 1x106 or even 104
WASHED RBC
The cause of most allergic reactions is plasma proteins. The washing of RBC removes
plasma proteins.
Washed RBC are used for the rare patients with IgA deficiency and anti-IgA antibodies
FROZEN DEGLYCEROLIZED RBC
Freezing RBC is done with endocryophylactic agent such as glycerol.
Two procedures may be employed:
High glycerol (40 percent weight per volume). The freezer must provide storage at minus 65oC
Low glycerol (20 percent weight per volume) liquid nitrogen freezing provides a storage temperature
of about -120oC
Freezing RBC with glycerol allows the long term storage of rare blood units, autologous units
and units for special purposes (such as intrauterine transfusion).
It has an extended shelf life of 10 yrs or more in frozen state
The process of deglycerolization removes nearly all leucocytes and plasma
Both washed RBC and deglycerolized RBC are to be used within 24 hours.
PLATELET CONCENTRATE
Function of platelets
Essential for the formation of the primary hemostatic plug and maintenance of normal
homeostasis
Thrombocytopenia maybe caused by:
Decreased platelet production (after chemotherapy or malignancy)
Increased destruction (DIC)
Massive transfusion (because of the rapid use of platelets for hemostasis and the dilution of
platelets by resuscitation fluids and stored blood
Platelet transfusion are indicated for patients
Who are bleeding due to thrombocytopenia
Who have platelets abnormally functioning
Who have platelet counts under 20,000/uL (prophylaxis)
Who have undergone chemotherapy, DIC and massive transfusion
PLATELET CONCENTRATE
PREPARATION
Whole blood is maintained at 20-24oC before and during preparation. The centrifuge is set at 22oC.
Light spin centrifugation refers to 3,200 rpm spin for 2-3 minutes. This spin is necessary to separate most
of the RBC but leave most of the platelets suspended in plasma
After light spin, the platelet rich plasma is expressed off until enough plasma must remain on the RBC to
maintain a 70 to 80% hematocrit
The PRP is recentrifuged at 22oC using a heavy spin (approximately 3,600 rpm for 5 minutes). This will
separate the platelets from the plasma
After heavy spin, the plasma is expressed off leaving approximately 50 to 70 ml on the platelets. The
platelet concentrate must have a pH of 6.0 during storage. (The remaining plasma may be frozen as
fresh frozen plasma(FFP) or single donor plasma frozen within 24 hours (SDP-24) or stored as liquid
recovered plasma
Platelet concentrate is allowed to lie undisturbed for 1 to 2 hours at 20-24oC to allow the platelets to
disaggregate
PLATELET CONCENTRATE
PREPARATION
Platelets are then resuspended on a rotator with constant gentle agitation at 20-24oC to
ensure reliability Particular care must be taken to avoid bacterial contamination
The shelf life is 5 days from the date of collection. If the system is opened, transfusion must be
done within 6 hours
All of the units for a single dose (typically 6 to 8 units for an adult) can be pooled in a single bag
before transfusion. Once pooled, the product must be transfused within 4 hours of pooling
PLATELET CONCENTRATE
COMPONENT
Each unit of platelet concentrate must contain at least 5.5x1010 platelets; stored at 20-24oC
with continuous agitation, contains 50 to 70 ml plasma, pH >6 and has a shelf life of 5 days
Each unit of platelet concentrate should increase the platelet count by 5,000 to 10,000 in the
typical 70 kg human
Platelet components maybe washed to remove plasma proteins that cause severe allergic
reactions
Washed platelet concentrate requires a 4-hours expiration time
Platelet concentrate may be contaminated by RBC and WBC and may cause alloimmunization
of the recipient. Therefore, a platelet concentrate by an Rh-positive donor should not be
administered to an Rh-negative woman of childbearing age to avoid alloimmunization to the D
antigen of the donor
PLATELET CONCENTRATE
PLATELETPHERESIS
Component is prepared from one donor and must contain a minimum of 3x1011 platelets,
stored at 20-24oC with agitation, contains approximately 300 ml plasma and has a shelf life of 5
days
One plateletpheresis component is equivalent to one dose of random platelet concentrate (a
pool of 4 to 6 units)
It is generally indicated for patients who are unresponsive or refractory to random platelets
due to HLA alloimmunization or to limit exposure to multiple donors
PLATELET CONCENTRATE
PLATELET COUNT INCREMENT
A corrected platelet count increment using a 1-hr post-infusion blood sample can
provide patient’s response to a platelet component
Formula:
Absolute platelet increment/ul x body surface
Number of platelets transfused
Note: absolute platelet increment is the post transfusion platelet count minus the pre-
transfusion platelet count, the body surface area is expressed as square meters, and
the number of platelets transfused is determined by multiplying the number of units
(bags) of platelets by 0.55 (the number of platelets in each unit of concentrate
expressed in 1011)
PLATELET CONCENTRATE
PLATELET COUNT INCREMENT
Example: A patient with 10,000/uL platlet count has a body surface area of 1.3 m2. Six
units of platelets were given. The 1-hr post transfusion platelet count is 50,000/uL
What is the corrected platelet count?

(50,000/uL-10,000/uL) x 1.3 = 15, 758/Ul

6 units x 0.55/unit
The answer shows that the patient has a good increment
>10,000/uL and is not refractory to platelets
<5,000/uL indicates refractoriness
The formula can be used for plateletpheresis by using 3 ( times 1011) as the number of
platelets in each unit
GRANULOCYTAPHERESIS AND BUFFY COAT
Patients develop neutropenia and serious bacterial and fungal infection after receiving
intensive chemotherapy or bone marrow transplant or both
Granulocyte transfusions are done in
Cases of fever
Neutrophil count less than 500/uL
Septicemia or bacterial infection unresponsive to antibiotics
Reversible bone marrow hypoplasia
Reasonable chance for patient survival
Neonates with impaired neutrophil function
GRANULOCYTAPHERESIS AND BUFFY COAT
Granulocyte concentrates are prepared by cytapheresis. Each product contain 1x1010
granulocytes if steroids (corticosteroid) or hydroxyethyl starch (HES) or both are used
Corticosteroids are administered to the donor 12 to 24 hours before pheresis to increase the
number of circulating granulocytes by pulling them from marginating pool
Hydroxyethyl starch (HES) is a sedimenting agent that increases the separation between WBC
or RBC thus facilitating the recovery of the buffy coat
Granulocyte concentrates contain 200 to 600 ml plasma, stored at 20-24oC and shelf life is 24
hours
Dosage
For adults, the usual dose is one granulocytapheresis product daily for 4 or more days
For neonates, a buffy coat or a granulocytapheresis unit is usually given once or twice
FRESH FROZEN PLASMA (FFP)
FFP is prepared from fresh whole blood within 6 hours of collection, hence, must be preserved by
prompt rapid freezing
FFP is used to treat multiple coagulation deficiencies occurring in patients with
Liver failure
DIC
Vitamin K deficiency
Warfarin toxicity
Massive transfusion
FFP should not be used for blood volume expansion or protein replacement because safer products are
available for these purposes such as:
Serum albumin
Synthetic colloids
Balanced salt solutions
FFP should be ABO compatible with the recipient’s RBC’s but the Rh type can be disregarded
FRESH FROZEN PLASMA (FFP)
FFP or SDP-24 is a frequent by-product of concentrated RBC and platelet concentrate
production:
For FFP, plasma must be frozen within 8 hours of collection if the anticoagulant used
is CPD, CP2D or CPDA-1. It can be stored at -30oC for 12 months
For SDP-24, plasma must be frozen within 24 hours of collection and stored at -18oC
or colder
PLASMA (FROZEN PLASMA AND STORED PLASMA)
Frozen plasma is separated from whole blood within 24 hours from the time of
collection
Stored plasma was formerly known as a liquid plasma or cryoprecipitate-poor plasma.
It is separated from whole blood after 24 hours of storage at 4oC. Plasma has small
amounts of Factors V and VIII and thus is not recommended for patients with
deficiency of either or both of these clotting factors
Plasma is used
For the treatment of stable coagulation deficiency especially factor XI
As a storage of plasma for patients undergoing plasma exchange
Frozen plasma can be stored at -30oC for up to 12 months
CRYOPRECIPITATED ANTI-HEMOPHILIC FACTOR
Anti hemophilic factor (AHF) is also called factor VIII. It is the cold precipitated
concentration of Factor VIII
Cryoprecipitated AHF also contains fibrinogen, von Willebrand’s factor (vWF) and
Factor XIII
Each unit of cryoprecipitate must contain at least 80 units of Factor VIII
Cryoprecipitated AHF is used primarily for fibrinogen replacement in patients with liver
failure or DIC. It can also be used as a source of fibrin glue, which is applied topically on
prosthetic vascular graft as well as vascular tissue planes in surgery
It is prepared from FFP by freezing at -70oC followed by thawing at 4oC
Cryosupernate is the residual plasma frozen after removal of cryoprecipitate
FACTOR VIII CONCENTRATE
Prepared by pharmaceutical firms by fractionation and lyophilization of pooled plasma
Derived from plasma obtained by plasmapheresis or from volunteer blood donors
Stored at refrigerator temperature and is reconstituted with saline at the time of
infusion
Used to treat patients with Hemophilia A or Factor VIII deficiency
FACTOR VIII CONCENTRATE
Prepared from large volumes of pooled plasma, the methods employed to inactivate or eliminate virus
contamination of the product include:
Pasteurization – involves heating the product to 60oC for 10 hours using albumin, sucrose or glycine as
a stabilizer (to prevent denaturation), stabilizers are then removed and then lyophilized
Solvent and detergent disrupt the viral coat chemically to inactivate any virus present
The solvents used are ethyl ether and tri-(n-butyl)phosphate (TNBP)
The detergents used are cholate and Tween 80
The concentrate is purified to remove the solvent and detergent and then lyophilized
Monoclonal Purification – done by immunoaffinity chromatography, it uses murine monoclonal
antibody directed at Factor VIII or von Willebrand’s factor (vWF) moiety bound on a solid phase
substrate to selectively absorb the factor VIII: vWF complexes, product is then lyophilized
Recombinant products obtained through recombinant DNA technology are made available after the
identification and isolation of the gene or human Factor VIII
Porcine Factor VIII is made from porcine (pig) plasma
1-Deamino-beta-D-arginine vasopressin is a synthetic analog of vasopressin. When injected, the
endothelial cells release intracellular stores of Factor VIII and vWF
FACTOR VIII CONCENTRATE
FACTOR IX CONCENTRATE
Prepared from pooled plasma using various methods of separation and viral
inactivation
Factor IX complex concentrate (prothrombin complex) contains Factor II, VII, IX and X
Factor IX concentrate is indicated only for Factor IX deficiency (Hemophilia B)
ANTI-THROMBIN III
Anti-thrombin III is a protease inhibitor with activity toward thrombin
Liquid plasma and FFP are alternative sources of anti-thrombin III
OTHER CONCENTRATES
Protein C is a vitamin K-dependent factor and serine protease inhibitor. It inactivates
factors V and VIII thus preventing thrombus formation
Alpha protease inhibitor concentrates are used for patients with alpha-1-antitrypsin
deficiency, which is associated with emphysema and liver disease
C1-esterase inhibitor concentrates for the treatment of life-threatening angloedema of
the mucosa and submucosa of the respiratory and gastrointestinal tract
ALBUMIN AND PLASMA PROTEIN FRACTION
Albumin and plasma protein fraction are prepared by chemical fractionation of pooled
plasma
Plasma protein fraction is available only as a 5 percent solution containing 83 percent
albumin and 17v percent globulin
Albumin and FFP are used to treat patients requiring volume replacements
Albumin is used routinely as the replacement fluid in plasmapheresis procedures; and
in the treatment of burn patients
IMMUNE GLOBULIN
Immune globulin (Ig) is primarily IgG prepared from pooled plasma
Ig is available for intravenous or intramuscular administration
Intramuscular product must not be given intravenously because severe anaphylactic
reaction may occur
Intravenous product is given slowly to lessen the risk of infection
Ig is used for:
Patients with congenital hypogammaglobulinemia (both IM and IV administration)
Patients exposed to hepatitis A or measles (IM administration)
Patients with immune thrombocytopenia (ITP) and myasthenia gravis
IMMUNE GLOBULIN
Hyperimmuneglobulins
Available for the prevention of hepatitis B, Varicella, zoster rabies and mumps
These are prepared from the plasma of donors who have high antibody titers to the
specific virus causing the disease
RhIg is used to prevent immunization of Rh negative mother pregnant with Rh-
positive infant
Hyperimmuneglobulins may cause anaphylactic reactions especially for patients
with IgA deficiency and previous anaphylactic reactions to blood components
NORMAL SERUM ALBUMIN (NSA)
NSA is prepared from salvaged plasma, pooled and fractionated by a cold alcohol
process, then treated with heat inactivation
NSA is used a colloid volume expander in patients who are hypovolemic and
hypoproteinemic
SYNTHETIC VOLUME EXPANDERS
Normal saline
Ringer’s solution
Ringer’s lactate
Balanced electrolyte solution
Dextran (high or low molecular weight)
HES (Hydroxyethyl Starch)