Blood plasma

From Wikipedia, the free encyclopedia

Blood plasma is the yellow liquid component of blood, in which the blood cells in whole blood would normally be

suspended. It makes up about 55% of the total blood volume. It is theintravascular fluid part of extracellular fluid. It is

mostly water (90% by volume) and contains dissolved proteins, glucose, clotting factors, mineral ions, hormones and

carbon dioxide (plasma being the main medium for excretory product transportation). Blood plasma is prepared

by spinning a tube of fresh blood containing an anti-coagulant in a centrifuge until the blood cells fall to the bottom of

the tube. The blood plasma is then poured or drawn off.[1] Blood plasma has a density of approximately 1025 kg/m3,

or 1.025 kg/l.[2]

Blood serum is blood plasma without fibrinogen or the other clotting factors (i.e., whole blood minus both the

cells and the clotting factors).[1]

Plasmapheresis is a medical therapy that involves blood plasma extraction, treatment, and reintegration.

Contents
[hide]

• 1 Fresh frozen plasma and other transfused

plasmas

• 2 Dried plasma

• 3 Composition

• 4 Plasma shift

• 5 See also

• 6 References

• 7 External links

[edit]Fresh frozen plasma and other transfused plasmas

Main article: Fresh frozen plasma

"Fresh frozen plasma" (FFP) is prepared from a single unit of blood or by apheresis, drawn from a single person. It is

frozen to −40 °C (−40.0 °F) after collection and can be stored for tenyears from date of collection. The term "FFP" is

sometimes used informally to mean any frozen transfusable plasma product, including products which do not meet

the standards for FFP. FFP contains all of the coagulation factors and proteins present in the original unit of blood. It

is used to treat coagulopathies from warfarin overdose, liver disease, or dilutional coagulopathy. Other transfusable

plasma is identical except that the coagulation factors are no longer considered completely viable.[3] This is
particularly important for Factor VIII andhemophilia, but these have been mostly replaced by more specific Factor VIII

concentrates in the developed world and true FFP is rarely used for that indication.

Plasma used as a source of Cryoprecipitate (Plasma, Cryoprecipitate Reduced) cannot be used for treatment of

some coagulation problems but is still acceptable for many uses.

[edit]Dried plasma

Dried plasma packages used by Britain and US military during WWII

"Dried plasma" was developed and first used in WWII. Prior to the United States' involvement in the war, liquid

plasma and whole blood were used. The "Blood for Britain" program during the early 1940s was quite successful (and

popular in the United States) based on Dr. Charles Drew's contribution. A large project was begun in August of the

year 1940 to collect blood in New York Cityhospitals for the export of plasma to Britain. Dr. Drew was

appointed medical supervisor of the "Plasma for Britain" project. His notable contribution at this time was to transform

the test tube methods of many blood researchers, including himself, into the first successful mass

production techniques.
Nonetheless, the decision was made to develop a dried plasma package for the armed forces as it would reduce

breakage and make the transportation, packaging, and storage much simpler.[4]

The resulting Army-Navy dried plasma package came in two tin cans containing 400 cc bottles. One bottle contained

enoughdistilled water to completely reconstitute the dried plasma contained within the other bottle. In about

three minutes, the plasma would be ready to use and could stay fresh for around four hours.[5]

Following the "Plasma for Britain" invention, Dr. Drew was named director of the Red Cross blood bank and assistant

director of the National Research Council, in charge of blood collection for the United States Army and Navy. Dr.

Drew argued against the armed forces directive that blood/plasma was to be separated by the race of the donor. Dr.

Drew argued that there was no racial difference in human blood and that the policy would lead to

needless deaths as soldiers and sailors were required to wait for "same race" blood.[6]

By the end of the war the American Red Cross had provided enough blood for over six million plasma packages.

Most of the surplus plasma was returned to the United States for civilian use. Serum albumin replaced dried plasma

for combat use during the Korean War.[7]

[edit]Composition

Further information: Blood#Plasma

Reference ranges for blood tests, showing normal mass concentration of blood plasma consituents.

The same information, shown in molarity rather than mass.

[edit]Plasma shift

Blood plasma volume may be expanded by or drained to extravascular fluid when there are changes in Starling

forces across capillary walls. For example, when blood pressure drops incirculatory shock, Starling forces drive fluid

into the blood vessels, causing autotransfusion.

Also prolonged still standing causes an increase in transcapillary hydrostatic pressure. As a result, approximately

12% of blood plasma volume crosses into the extravascular compartment. This causes and increase

in hematocrit, serum total protein, blood viscosity and, as a result of increased concentration of coagulation factors, it

causes orthostatic hypercoagulability.[8]

Apheresis
From Wikipedia, the free encyclopedia

This article is about dialysis. For the linguistic term, see Apheresis (linguistics).

Whole blood enters the centrifuge (1) and separates into plasma (2), leukocytes (3), and erythrocytes (4). Selected components are then

drawn off (5).

Apheresis (plural aphereses; also spelled aphaeresis, aphæresis; from Ancient Greek ἀφαίρεσις (aphairesis, “a

taking away”)) is a medical technology in which the blood of a donor or patient is passed through an apparatus that

separates out one particular constituent and returns the remainder to the circulation. It is thus

an extracorporeal therapy.

Contents
[hide]

• 1 Method

o 1.1 Continuous flow centrifugation

(CFC)

o 1.2 Intermittent flow centrifugation

 o 1.3 Centrifugation Variables

• 2 Types of apheresis

o 2.1 Donation

 2.1.1 Donor Safety

 2.1.1.1 Kit

Problems

 2.1.1.2 Plasticizer

exposure

o 2.2 Therapy

• 3 Fluid replacement during apheresis

• 4 Intravenous immunoglobulin

• 5 See also

• 6 References

• 7 External links

[edit]Method

Depending on the substance that is being removed, different processes are employed in apheresis. If separation

by weight is required, centrifugation is the most common method. Other methods involve absorption onto beads

coated with an absorbent material and filtration.

The centrifugation method can be divided into two basic categories:

[edit]Continuous flow centrifugation (CFC)

Continuous flow centrifugation (CFC) historically required two venipunctures as the "continuous" means the blood is

collected, spun, and returned simultaneously. Newer systems can use a single venipuncture. The main advantage of

this system is the low extracorporeal volume (calculated by volume of the apheresis chamber, the donor's hematocrit,

and total blood volume of the donor) used in the procedure, which may be advantageous in the elderly and for

children.

[edit]Intermittent flow centrifugation

Intermittent flow centrifugation works in cycles, taking blood, spinning/processing it and then giving back the

necessary parts to the donor in a bolus. The main advantage is a single venipuncture site. To stop the blood from

coagulating, anticoagulant is automatically mixed with the blood as it is pumped from the body into the apheresis

machine.
[edit]Centrifugation Variables

The centrifugation process itself has four variables that can be controlled to selectively remove desired components.

The first is spin speed and bowl diameter, the second is "sit time" in centrifuge, the third is solutes added, and the

fourth is not as easily controllable: plasma volume and cellular content of the donor. The end product in most cases is

the classic sedimented blood sample with the RBC's at the bottom, the "buffy coat" of platelets and WBC's

(lymphocytes/granulocytes (PMN's, basophils, eosinophils/monocytes) in the middle and the plasma on top.

[edit]Types of apheresis

Disinfect, insert the cannula, pull out the cannula, dress the wound. The blue pressure cuff is controlled by the platelet apheresis machine in

newer models.

There are numerous types of apheresis.

[edit]Donation

Blood taken from a healthy donor can be separated into its component parts during blood donation, where the

needed component is collected and the "unused" components are returned to the donor. Fluid replacement is usually

not needed in these type of collections. There are large categories of component collections:

 Plasmapheresis - blood plasma. Plasmapheresis is useful in collecting FFP (fresh frozen plasma) of a

particular ABO group. Commercial uses aside from FFP for this procedure include immune globulin products,

plasma derivatives, and collection of rare WBC and RBC antibodies.

 Erythrocytapheresis- red blood cells. Erythrocytapheresis is the separation of erythrocytes from whole blood.

It is most commonly accomplished using the method of centrifugal sedimentation. This process is used for red

blood cell diseases such as sickle cell crises or severe malaria. The automated red blood cell collection

procedure for donating erythrocytes is referred to as 'Double Reds' or 'Double Red Cell Apheresis.'[1]
  Plateletpheresis (thrombapheresis, thrombocytapheresis) - blood platelets. Plateletpheresis, like it sounds, is

the collection of platelets by apheresis; while returning the RBC's, WBC's, and component plasma. The yield is

normally the equivalent of between six and ten random platelet concentrates. Quality control demands the

platelets from apheresis be equal to or greater than 3.0 x 10^11 in number and have a pH of equal to or greater

than 6.2 in 90% of the products tested and must be used within five days.

 Leukapheresis - leukocytes (white blood cells). Leukopheresis is the removal of PMN's, basophils,

eosinophils for transfusion into patients whose PMN's are ineffective or traditional therapy has failed. There is

limited data to suggest the benefit of granulocyte infusion. The complications of this procedure are the difficulty in

collection and short shelf life (24 hours at 20 to 24 C). Since the "buffy coat" layer sits directly atop the RBC

layer, HES, a sedimenting agent, is employed to improve yield while minimizing RBC collection. Quality control

demands the resultant concentrate be 1.0 x 10^10 granulocytes in 75% of the units tested and that the product

be irradiated to avoid graft-versus-host disease (inactivate lymphocytes). Irradiation does not affect PMN

function. Since there is usually a small amount of RBC's collected, ABO compatibility should be employed when

feasible.

 Stem cell harvesting - circulating bone marrow cells are harvested to use in bone marrow transplantation.

[edit]Donor Safety

 Single use kits - Apheresis is done using single-use kits, so there is no risk of infection from blood-

contaminated tubing or centrifuge.

 Immune system effects - "the immediate decreases in blood lymphocyte counts and serum immunoglobulin

concentrations are of slight to moderate degree and are without known adverse effects. Less information is

available regarding long-term alterations of the immune system" [2]

[edit]Kit Problems

Two apheresis kit recalls were:

 Baxter Healthcare Corporation (2005) in which "pinhole leaks were observed at the two-omega end of the

umbilicus (multilumen tubing), causing a blood leak. "[3]

 Fenwal Incorporated (2007) in which there were "two instances where the anticoagulant citrate dextrose

(ACD) and saline lines were reversed in the assembly process. The reversed line connections may not be

visually apparent in the monitor box, and could result in excessive ACD infusion and severe injury, including

death, to the donor." [4]

[edit]Plasticizer exposure

Apheresis uses plastics and tubing, which come into contact with the blood. The plastics are made of PVC in addition

to additives such as a plasticizer, often DEHP. DEHP leaches from the plastic into the blood, and people have begun

to study the possible effects of this leached DEHP on donors (as well as, obviously, transfusion recipients).

 "current risk or preventive limit values for DEHP such as the RfD of the US EPA (20 μg/kg/day) and the TDI

of the European Union (20-48 μg/kg/day) can be exceeded on the day of the plateletpheresis. . . . Especially

women in their reproductive age need to be protected from DEHP exposures exceeding the above mentioned

preventive limit values." [5]

 "Commercial plateletpheresis disposables release considerable amounts of DEHP during the apheresis

procedure, but the total dose of DEHP retained by the donor is within the normal range of DEHP exposure of the

general population." [6]

 The Baxter company manufactured blood bags without DEHP, but there was little demand for the product in

the marketplace [7]

 "Mean DEHP doses for both plateletpheresis techniques (18.1 and 32.3 μg/kg/day) were close to or

exceeded the reference dose (RfD) of the US EPA and tolerable daily intake (TDI) value of the EU on the day of

the apheresis. Therefore, margins of safety might be insufficient to protect especially young men and women in

their reproductive age from effects on reproductivity. At present, discontinuous-flow devices should be preferred

to avert conceivable health risks from plateletpheresis donors. Strategies to avoid DEHP exposure of donors

during apheresis need to be developed." [8]

[edit]Therapy

The assembly (A-D), operation (E) and disassembly (F) of the platelet apheresis machine which can be configured to separate other

components as well.

The various apheresis techniques may be used whenever the removed constituent is causing severe symptoms of

disease. Generally, apheresis has to be performed fairly often, and is an invasive process. It is therefore only

employed if other means to control a particular disease have failed, or the symptoms are of such a nature that waiting

for medication to become effective would cause suffering or risk of complications.

  LDL apheresis - removal of low density lipoprotein in patients with familial hypercholesterolemia.

 Photopheresis

 Immunoadsorbtion with Staphylococcal protein A-agarose column - removal of allo- and autoantibodies (in

autoimmune diseases, transplant rejection, hemophilia) by directing plasma through protein A-agarose columns.

Protein A is a cell wall component produced by several strains of Staphylococcus aureus which binds to the Fc

region of IgG.

[edit]Fluid replacement during apheresis

It is important to remember that when the apheresis system is used for therapy the system is removing relatively

small amounts of fluid (not more than 10.5 mL/kg body weight). That fluid must be replaced to keep correct

intravascular volume. The fluid replaced is different at different institutions. If a crystalloid like normal saline is used,
the infusion amount should be triple what is removed as the three to one ratio of NS for plasma is needed to keep up

oncotic pressure. Some institutions use normal serum albumin, but it is costly and can be difficult to find. Some

advocate using FFP or a similar blood product, but there are dangers including citrate toxicity (from the

anticoagulant), ABO incompatibility, infection, and cellular antigens.

[edit]Intravenous immunoglobulin

Intravenous immunoglobulin (IVIG) is a blood product administered intravenously. It contains the pooled IgG

immunoglobulins (antibodies extracted from the plasma of thousands of blood donors). IVIG is given as a protein

replacement therapy for immune deficient patients which have decreased or abolished antibody production

capabilities. IVIG is administered to maintain adequate antibodies levels to prevent infections and confers a passive

immunity. IVIG effects last between 2 weeks and 3 months. It is mainly used as treatment in three major categories:

 Immune deficiencies, such as X-linked agammaglobulinemia, hypogammaglobulinemia (primary immune

deficiencies), and acquired compromised immunity conditions (secondary immune deficiencies), featuring low

antibody levels;

 Inflammatory and autoimmune diseases

 Acute infections
Cryoprecipitate
From Wikipedia, the free encyclopedia

Cryoprecipitate, also called "Cryoprecipitated Antihemophilic Factor", "Cryoprecipitated AHF", and most commonly

just "cryo", is a frozen blood product prepared from plasma.

It is often transfused as a four to six unit pool instead of as a single product. Many uses of the product have been

replaced by factor concentrates, but it is still routinely stocked by manyhospital blood banks.

Like fresh frozen plasma, compatibility testing is not strictly necessary, but cryo is given as ABO compatible when

possible. Compatibility is reversed for plasma products: AB type is the universal plasma donor and O type is the

universal plasma recipient. Type AB plasma contains no A or B antibodies, whereas type O plasma has both A and B
antibodies.

Contents
[hide]

• 1 Composi

tion

• 2 Indicatio

ns

• 3 Manufac

ture

• 4 History
 • 5 Referenc

es

[edit]Composition

Each 15 mL unit typically contains 100 IU of factor VIII, and 250 mg of fibrinogen. It also contains von Willebrand

factor (vWF) and factor XIII.

US standards require manufacturers to test at least four units each month, and the products must have an average of

150 mg or more of fibrinogen and 80 IU of factor VIII.[1] Individual products may actually have less than these

amounts as long as the average remains above these minimums. Typical values for a unit are substantially higher,

and aside from infants it is rare to transfuse just one unit.

[edit]Indications

Indications for giving cryoprecipitate include:[2]

 Haemophilia - Used for emergency back up when factor concentrates are not available.

 von Willebrands's disease - Not currently recommended unless last reserve. dDAVP is first line, followed by

factor concentrates.

 Hypofibrinogenaemia (low fibrinogen levels), as can occur with massive transfusions

 Bleeding from excessive anticoagulation - FFP contains most of the coagulation factors and is a much better

choice when anticoagulation has to be reversed quickly.

 Massive haemorrhage - RBCs and volume expanders are preferred therapies.

 Disseminated intravascular coagulation

[edit]Manufacture

The product is manufactured by slowly thawing a unit of FFP at temperatures just above freezing (1-6 °C), typically in

a water bath or a refrigerator. The product is then centrifuged to remove the majority of the plasma, and the

precipitate is resuspended in the remaining plasma or in sterile saline. The product may be pooled and frozen or

frozen as individual units.

[edit]History

The first publication of the method of concentrating clotting factors from plasma was by Judith Graham

Pool at Stanford University in 1964, writing in Nature.[3]

Cryoprecipitate was originally known as "Cryoprecipitate AHF", where AHF stands for "Anti-hemophiliac factor." AHF

is now known as Factor VIII.

According to Dr. Charles Abildgaard, who was a Stanford medical resident at the time:

They obtained frozen plasma in very large containers that they got from Japan. They would thaw that and send her

[Pool] samples of the liquid parts to assay. She wasn't really finding very much Factor VIII activity, and then someone

mentioned to her that when they thawed this large amount of plasma, there was always some mucky stuff at the

bottom of it, and she said, "Well, send me some of that, too." She found that at least half of the Factor VIII activity

was in the residue. What was happening that, because of the large volume, as the mass thawed, it stayed cold. So

this was cryoprecipitate.[4]

Others had been close to discovering cryoprecipitate but failed to make the connection between the lack of plasma

clotting activity after thawing and the precipitate. According to Dr. Frederick Rickles:

I made a mistake in an experiment, and instead of putting frozen plasma back in the freezer at the end of the day's

experiment, I instead stuck it in the refrigerator. When I came in the next morning, there was all this junk in the bottom

of the tube which I spun out, and I used the plasma for my experiment. My experiment didn't work because there was

no Factor VIII in it. And I went back and fished the junk out of the trash and assayed the junk and got these

outrageously high values for Factor VIII in the junk, and neither Charlie nor I believed it, and so it was one of those

things. And sure enough, about a year later Judith Graham Pool discovered cryoprecipitate.[4]