BLOOD COMPONENT THERAPY

DR RIZWAN ANSARI
FCPS ANESTHESIOLOGY
 INTRODUCTION
 Blood is a specialized body fluid.
 Blood is composed of PLASMA(55%) and
FORMED ELEMENT(45%)
 MAIN FUNCTIONS OF BLOOD
Transporting oxygen and nutrients to
the lungs and tissues.

Forming blood clots to prevent excess

blood loss.

Carrying cells and antibodies that fight

infection.
 BLOOD COMPONENT THERAPY

The goal of transfusion is to :

 Aim to give the right blood products to the right patients at the
right time in the right amount.

 Efficiently correct tissue hypoperfusion

 Prevent coagulopathy

 Anaemic hypoxaemia

 Minimising the risk of transfusion-related adverse outcomes for patients.

STEPS OF BLOOD AND ITS COMPONENT COLLECTION

1. Donation

2. Compatibility Testing

3. Screening for infectious diseases

4. Blood processing
 Donation and testing
 Whole blood donation
Each donor provides 500mL of blood. A
total of 470mL goes on to be processed
while 30mL is utilised for routine testing.
Donors can typically give blood four times
annually

Apheresis donation
A cell separator is used to collect plasma,
platelets, white cells or haematopoietic
progenitor cells. Donor red cells are returned
to the donor. Donors may give these fractions
every 2weeks
PLATELET APHRESIS
 Compatibility testing
ABO compatibility prevents acute haemolytic transfusion
reactions caused by recipient IgM antibodies binding A or B
antigens on donor red cells.

 Red cells express ABO antigens and recipients must be transfused with
ABO-compatible units to prevent serious harm or death.

Platelets weakly express ABO antigens. Therefore, recipients should be

transfused with ABO-compatible units. Non-​ABO-compatible units of
platelets can be used in the event of life-threatening haemorrhage, but
these platelets will have a reduced lifespan

Cryoprecipitate and FFP contain anti-B or anti-​A IgM antibodies,

depending on the donor blood group. For donated plasma to be
compatible, it must not contain IgM antibodies against antigens
expressed on recipient cells.
 RhD compatibility
 Red cells express RhD antigens. This is of particular
importance for all ♀ of reproductive potential to prevent
future haemolytic disease of the newborn (due to maternal
anti-D harming RhD-positive fetuses).

Platelets do not express RhD antigens. However, units

should be RhDcompatible with the recipient as the RhD
antigen is highly immunogenic and residual red cells in the
units may sensitise RhD-negative patients

Cryoprecipitate and FFP may contain red cell fragments;

however, these are far less immunogenic than whole red
cells. Therefore, cryoprecipitate and FFP of any RhD type
can be safely given.
 BLOOD COMPONENTS
PACKED RED BLOOD CELL(PRBC)
Derived from Centrifuged from
singledonor whole blood
Composed of Hct 50–70%
suspended in SAGM
The glucose provides an energy
source for the metabolic requirements
of the cells, and adenine helps
maintain cellular levels of ATP. Saline
and mannitol provide an aqueous
medium of appropriate osmolality and
pH.
Volume 300mL Storage 2–6°C
Shelf-life 35d Dose 4mL/kg will increase Hb by 1g/dL
 Platelets
Derived from centrifugation from 4–6 whole blood
donations or by apheresis from a single donor
Composition >240 × 109 platelets

Volume 300mL

storage 20–24°C on an agitator

Shelf-life 7days

Dose 1 unit will increase platelet

count by 20–40 × 109 /L
 FRESH FROZEN PLASMA
Derived from Apheresis donation from a male
donor. Rapidly frozen within 8h of donation

COMPOSITION: 0.5g fibrinogen, factor VII

>0.7IU/mL, labile factors

Volume 300mL

STORAGE –30°C

SHELF LIFE 2y (frozen) 4h (thawed 2–6°C)

DOSE 10–15mL/kg
 Cryoprecipitate
Controlled thawing of single-
donor FFP. Pooled from 4–6 donors
COMPOSITION :2g fibrinogen, vWF, factor
VIII, factor XIII, fibronectin, factor VII
>1.5IU/mL

VOLUME Pooled 100–200mL

STORAGE –30°C
SHELF LIFE 2y (frozen) 4h (thawed room temp)
DOSE 1 unit per 30kg body
weight to increase plasma
fibrinogen by 1.0g/L
 Other derived products
Fibrinogen concentrate
Freeze-dried powder containing 1g
of purified human fibrinogen

Stored at room temperature for up to 3 month

 Raises a patient’s fibrinogen by 0.25g/dL

No thawing or blood type

matching is required.
COST $2300
 Recombinant factor VIIa

 A freeze-dried powder

 used in patients with congenital

factor VII deficiency, in bleeding
episodes in patients with haemophilia
A or B, with inhibitors to factors VIII or
IX, and occasionally in those with
severe uncontrolled bleeding as part of
a massive transfusion.
Dose is 90 micrograms/kg IV
 Prothrombin complex concentrate Prothrombinex®)
 It is asterile, freeze-dried powder
for reconstitution containing 500IU
of purified human factors II, XII and
X.

Dosing is dependent on
coagulation studies, desired
clotting profile, patient weight and
the factor deficiency being
reversed.
Used to replace congenital factor
deficiencies when purified single-
factor concentrates are
unavailable, or for the reversal of
vitamin K antagonist anticoagulants
(e.g. warfarin)
 Safe transfusion

 Informed consent.

Confirm patient identity, verbally with the patient if

possible and by identification band.

 Check unit to be transfused against prescription.

Check unit is within expiry date and that unit numbers

match between the laboratorygenerated label attached to
the pack and the pack itself.
Inspect the bag, ensuring integrity of the plastic
casing. Look for discoloration or evidence of
clumping.

 Infuse through a blood administration set with a

170–200 micrometres integral screen filter.
Typically each filter can be used for 4 units of
packed red cells during normal transfusion or 8–10
units during a massive transfusion, provided flow
rates are adequate without evidence of clogging of
the filter.
Platelet concentrates should not be infused
through giving sets that have been used for red
cells due to risk of clumping. Infuse each unit
within recommended time frames

Monitor for adverse events.

Documentation. A 100% traceability of

transfused blood is a legal requirement around
world.
Management of hemolytic reactions can be
summarized as follows:
1. If a hemolytic reaction is suspected, the transfusion should be stopped
immediately and the blood bank should be notified.

2. The unit should be rechecked against the blood slip and the patient’s identity
bracelet.

3. Blood should be drawn to identify hemoglobin in plasma, to repeat

compatibility testing, and to obtain coagulation studies and a platelet count.

4. A urinary bladder catheter should be inserted, and the urine should be

checked for hemoglobin.

5. Forced diuresis should be initiated with mannitol and intravenous fluids, and
with a loop diuretic if necessary.
 Transfusion indications and triggers

Clinical judgement, lab results, POCT and best available evidence

determine the blood components to be prescribed, as well as the
timing, dose and rate of administration

Globally, red cell transfusion policies have become increasingly

restrictive in response to emerging evidence of harm associated with
unnecessary transfusion. FFP should not be given for prolonged PT or
INR in the absence of bleeding
 TRANSFUSION RISK
Common
 Febrile non-haemolytic transfusion reaction
(1–3:100) occurs within 30min of transfusion and is mediated by
either cytokines or alloimmune reactions to contaminant
leucocytes. Simple cooling and paracetamol are sufficient for mild
reactions

Minor allergy
(1–5:500) commonly presents with mucocutaneous
manifestations, flushing, angio-oedema or urticaria due to
recipient antibodies against leucocyte antigens or plasma
proteins.
Transfusion-associated circulatory overload)
(1–10:1000 Incidence is determined by both the volume
transfused and patient comorbidity.

Hypothermia
Prevalent in rapid infusions of large volumes of blood
products. Can worsen all physiological processes, including
cardiovascular function and coagulation.

Immunosuppression. Transfusion may influence

the recurrence or spread of malignancies, as well as the
incidence of postoperative bacterial infections through
immunomodulation
 Rare complication
 Acute haemolytic transfusion reaction
(1–8:100 000). Severe, lifethreatening reaction occurring within
24h of red cell transfusion due to ABO incompatibility. Recipient
antibodies bind to and haemolyse transfused erythrocytes,
causing complement activation, inflammation, DIC and shock.
Signs and symptoms may be indistinguishable from bacterial
sepsis or anaphylaxis

Delayed haemolytic transfusion reaction

(1:5000). Usually occurs within 7d but may occur up to 28d after
transfusion due to previous recipient allosensitisation to
erythrocyte antigens during pregnancy or a previous transfusion.
Results in jaundice, anaemia and rarely splenomegaly and renal
injury due to haemoglobinaemia.
 TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)
(<1:5000).). Non-cardiogenic pulmonary oedema which occurs
within 6h of transfusion of plasma or plasma-containing
components.. Severe microvascular injury results from recipient
antibody reactions against transfused leucocyte or neutrophil
antigen.
 Viral infection
Screening of donors and donated blood for viral infections
reduce most risk. Residual risk results from individuals donating
blood during ‘window periods’ of active viral infection.

TA-GvHD
A usually fatal complication occurring 1–6w following transfusion.
Transfused viable lymphocytes engraft within an immunocompromised
host. These engrafted lymphocytes proliferate and precipitate
multiorgan failure and death through autoimmunity
THANK YOU
 Massive transfusion
DEFINITION

More than 5 units of PRBCs transfused in <4hrs or 10 units of

PRBCs administered to a patient within 24h is considered as
massive transfusion.
 Physiology of massive haemorrhage and transfusion
Rapid, large-volume haemorrhage results in systemic hypoperfusion and
reduced O2 delivery to tissues, causing acidosis.

Hypoperfusion also activates the protein C pathway, deactivating factors Va

and VIIIa and initiating fibrinolysis and coagulopathy. Consumption of clotting
factors may lead to DIC.

 Administration of cold IV fluids and exposure of the patient for vascular

access and resuscitation may lead to hypothermia. Hypothermia and acidosis
reduce myocardial contractility, precipitate bradycardia and dysrhythmias and
cause vasodilation and hypotension.

They also reduce activity of clotting factors and platelets, with clotting factor
function d by 10% for every 0.1 reduction in pH. Transfused red cells are not as
effective at O2 delivery as endogenous red cells
 Resuscitation priorities during massive haemorrhage and
transfusion

1. Adequate staffing and assistance

2. Maintain circulating volume

Obtain rapid source control of haemorrhage (e.g. surgical, endoscopic,
interventional radiology).

Immediately request 3 units of PRBCs;

use O-negative emergency blood if X-matched blood not immediately

available.

Obtain large-bore IV access; give crystalloid until blood arrives.

Increase FiO2 to 100% to improve tissue O2 delivery.

Consider reducing dose of anaesthetic agent administered.

3. Prevent hypothermia
Forced air warming devices (e.g. Bair Hugger™) • Increasing the
ambient room temperature

Infusing fluids via fluid warmers.

4. Prevent and treat coagulopathy

Balanced transfusion of blood products in 1:1:1 ratio.

Identify factor deficiencies and detect DIC. ABG, formal FBC,

coagulation studies and electrolytes sent to the lab and marked as
urgent—should be performed every 30min.

Consider dose of antifibrinolytic (tranexamic acid, 1g IV over

10min) if within 3h of traumatic event. •
Consider recombinant factor VIIa (NovoSeven®; 90
micrograms/kg IV) if surgical bleeding controlled and pH
>7.2. Use with caution in patients at risk of thrombosis
and discuss with haematologist.

Discuss with haematologist in non-surgical uncontrolled

bleeding (e.g. variceal bleeding) unresponsive to
PRBCs/FFP/platelets, anticoagulated patients or patients
with inherited bleeding disorders.

Treat sequelae of massive transfusion

Treat Citrate toxicity which causes hypocalcemia and Treat

Hyperkalemia by giving slow IV injection of 10mL of calcium
chloride 10%
 Treatment goals

Mean arterial pressure: Do not aim to normalise until there is

surgical control. >50mmHg (>70mmHg if head injury).

Haemoglobin : >7g/dL.

Fibrinogen : >1.5g/L (>2g/L in obstetric patients).

Platelets : >75 × 109 /L.

Ionised calcium : >1mmol/L on blood gas sample.

pH : 7.35–7.45. mmol/L on blood gas sample.

PT/APTT : <1.5 times upper limits of normal

THANK YOU