Rational Use of Blood

Components
Dr. M. Mohandoss
Assistant Professor
Transfusion Medicine,
Malabar Cancer Centre, Thalaserry

Component Therapy

1. Optimal preservation of in vitro function of blood

2. Efficient utilization of blood donations

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MALABAR CANCER CENTRE

Methods of Component Preparation

Whole Blood

Platelet Rich
Plasma
Method
Manual
Method
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Apheresis

Buffy Coat
Method
Automation
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Platelet Rich Plasma (PRP) method

Whole blood
Soft spin
within
(1800 rpm
6 hrs
x 9 min at 22oC)

Red cells

PRP

RBC

Platelet rich plasma (PRP)

Hard spin
(3000 rpm
PRP
x 7 min at 22oC)

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Plasma
Platelet Conc.
FFP
PC
(RDP)
MALABAR CANCER CENTRE

PRP Method
Manual plasma expresser

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MALABAR CANCER CENTRE

Buffy Coat method

Whole blood
Hard spin
(3000 rpm
x 9 min at 22oC)

Red cells

within
6 hrs

Plasma

RBC

Buffy coat

plasma

Soft spin
(1800 rpm x 7 min at 22oC)

Platelet Conc.
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WBC with few RBC

MALABAR CANCER CENTRE

Benefits of Buffy coat method

Platelet yield improved a lot
Reduced WBCs in product
RBC contamination drastically
decreased

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MALABAR CANCER CENTRE

Blood Component Extractor

Sealers

Sealer

Sensor

Sensors

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Press

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Apheresis
To take away or Withdraw
Process in which blood is removed from a
subject and continuously separated into
component parts, allowing a desired
component (s) to be retained while the
remainder is returned to the subject

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MALABAR CANCER CENTRE

Principle of Apheresis

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MALABAR CANCER CENTRE

SDP Vs RDP
Decreased chances of TTI and alloimmunization
number of donor support required
Lesser Donor reactions
Ensures adequate dose
ABO matched platelet support
Consistent and standardized yield

= 1 adult dose
(3x 1011/ unit)

SDP

RDP

RDP

+ RDP +

RDP

RDP

RDP

= 1 adult dose
(4 x 1010/unit)

Storage
COMPONENTS
Packed red blood cells (PRBC)
Platelets (PLTS)
Fresh frozen plasma (FFP)
Cryoprecipitate (CRYO)

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STORAGE
TEMPERATURE
+2 to 6C
+22 to +24C under
constant agitation
-30C or below
-30C or below

MALABAR CANCER CENTRE

Answer 4 Qs before transfusion

Why to transfuse ?
benefit > risk
patients symptoms Vs lab levels
prophylactic Vs therapeutic
What to transfuse ?
whole blood NO
components / fractions (FFP or 5% albumin)
How much to transfuse ?
Single unit
calculate volume
How to transfuse ?
use of filter
rate of transfusion
warming

Case 1
A patient X (45yr Male) admitted following road
traffic accident
Suspected to have blunt abdominal injury and
internal bleeding
Shifted to OT Hb:8g%
Which component would you like to transfuse?
1. Whole blood
2. Packed Red Blood Cells
3. Fresh Frozen Plasma

Whole blood in True

sense.

Whole blood is not

Whole!
After 24hrs of storage WB essentially
becomes red cells suspended in a protein
solution
Changes in Platelets
WB stored at 4C platelets rapidly lose
viability
After 8 hrs in vivo survival reduced to 2 days
Granulocytes & Monocytes function reduced
within 8hrs and disintegrates within 24hrs
Microaggregates increase in number
FVIII, FV levels decreases

Why whole blood is not

rational?
Maximize blood resource

whole blood one patient

component therapy

four patients

Packed red cells thalassemia

Plasma
liver disease / burns
Platelets thrombocytopenia
Cryoprecipitate hemophilia
Decrease cost of management

except for the cost of bag, other expenses

remain same

Why whole blood is not

rational?

Better patient management

concentrated dose of required component
avoid circulatory overload
minimizes reactions

Why whole blood is not

rational?
Example 1: Requirement of platelets to raise
count from 20 to 50,000/ul

fresh whole blood

random platelets
apheresis platelets

5 units
1750 ml
5 units
250 ml
1 unit
200 ml

Example 2: Requirement of fVIII to stop bleed in

hemophilic patient

fresh whole blood

cryoprecipitate

20 units 7,000 ml
20 units 400 ml

Modern transfusion therapy

.means component therapy

Optimal preservation of in vitro function of

blood
More effective treatment by specific
replacement of deficiency
Efficient utilization of blood donations
The proper use of blood requires:Knowledge of pathophysiology of condition
being treated
Identification of the specific deficiency needed
by the patient
Choice of appropriate component for therapy

Case 2
A 4 year old boy with thalassemia is on
hypertransfusion therapy.
Since last 3 months patient gets fever and chills
following transfusion
Did not get any benefit with premedication

Which component will you recommend for transfusion?

Irrradiated PRBC
Leukofiltered PRBC
Minor phenotype matched cells
Blood from his family member

storage time
passenger leukocytes

Transfused Leukocytes

Cytokine generation in stored

PC

Cytokine production in
vivo

Circulating cytokine

Threshold
Exceeded

IL - 1
IL 6
IL 8
TNF-

FNHTR

RANTE
S
TGF-
GRO-

Leuko-depleted Blood
Components
Adverse Effects due to Leukocytes
Febrile Nonhemolytic Transfusion Reaction
HLA alloimmunization
Cytomegalovirus transmission and
Reactivation
TRIM (Immunomodulation)
Leukoreduction
Prestorage
Post storage
- Centrifugation: BC removal - Laboratory
- Filtration
- Bedside

Indications for Leukoreduced

blood
Recommended

FNHTRs (Febrile non haemolytic

transfusion reactions)
To prevent recurrent FNHTRs
To prevent HLA alloimmunization
Prevention of transmission of CMV
Fetal/Neonatal transfusions.
Possible

Platelet refractoriness
Immunomodulation
Prevention of post-op bacterial
infection

Irradiated Blood Products

Irradiation of cellular components with
ionizing radiation results in the inactivation
of T-lymphocytes
The damage to T-lymphocytes DNA
prevents post infusion proliferation that
abrogates the potential for GVHD
Minimum dose 15- 25Gy
Reduced shelf life (28 days)

Clinical Indications For Irradiated Products

Congenital Immunodeficiency
Hematologic malignancy
Recipient of Stem cell transplant
Familial Blood Donation
Recipient of HLA matched Product
Intrauterine transfusion
Premature infants

Case 3
32 years / Male, fever since 6 days
Dengue Fever, no signs of bleeding
Platelet count 15,000/L
Hb: 13g/dL
PT, INR - normal
APTT are mildly elevated

Virus induced BM
suppression
Immune Mediated
Clearance
Increased
- Auto Ab ThrombocytopeniaConsumption
- Cross-reacting
antibodies

Platelet Dysfunction
Evidenced by the absence of ADP release
and impaired aggregation

Recommendations for Platelet Transfusion in Dengue

Stable patients with platelet count <10,000/L

Patients with platelet count <20,000/L with
minor bleed
Patients with platelet count <50,000 /L with
significant bleed

Apheresis Derived Platelet Concentrates

Rate of alloimmunization

Decreased incidence of T T I

COST

Fewer donor exposures

Monitoring of dose feasible

1 dose

SDP

ABO / Rh, HLA / HPA matching possible

RDP

Case 4
Within 30 to 45 minutes
52 years / Male
Known case of cirrhosis post transfusion
- Patient developed severe
Patient was posted for endoscopy
breathlessness
Laboratory Values
- Oxygen saturation
Hb: 9.5g/dL,
declined
PT:20 sec
- Even with oxygen mask
INR: 1.6
he was tachypneic and
Transfused 2 units of FFP his condition continued
to worsen..

???....
Was FFP transfusion appropriate?
If yes was it a sufficient dose? (weight 60kg)
What was the condition that patient developed after
transfusion?
Minimally elevated PT-INR
Recommendations for FFP transfusion
Correction of acquired deficiencies of clotting factors
when the PT or aPTT ratio is >1.5
Liver disease: Active bleeding

BCSH guidelines for use of FFP

Definite indications for the use of FFP

Single factor deficiency where specific factor conc is not
available
Immediate reversal of warfarin effect
Acute DIC
TTP

Conditional use of FFP in the presence of bleeding &

disturbed coagulation
Massive transfusion
Liver disease with active bleeding
No justifications for the use of FFP
Hypovolemia
Nutritional support
Treatment of immunodeficiency states

Use of Combination of
Components
Case 1
Patient continues to bleed
Visceral injuries noted
Hemostasis not achieved

2 U PRBC

10
U

Massive Transfusion Protocol

To standardize blood product support during
the early chaotic phase of
resuscitation.
Allow early administration of blood
components, especially FFP
Minimizing IV fluid resuscitation

Cryoprecipitate
Composition

vol
10-20 ml
f VIII
65 - 80 IU/unit
vWF:Ag 70 - 80 IU/unit
Fibrinogen 200 mg /unit
Fibronectin 55mg/unit
factor XIII 20-30% of
original

Cryoprecipitate.
Major Indications
Hypofibrinogenemia
FXIII deficiency
Hemophilia A
von Willebrands disease
Dosage: 1 bag / 7kg body wt
Fibrinogen deficiency
FVIII : Desired factor increase x 0.5

Current Transfusion Practice

Rate of Inappropriate transfusions *
RBC: 16% - 55.3%
Platelets: 13% - 48.7%
FFP: 31% - 45%

* References:
Blood Transfus. 2007 Apr;5(2):75-84. doi: 10.2450/2007.0015-07
Med J Aust. 2003 Feb 3;178(3):117-21
Transfusion. 2010 Dec;50(12):2565-70. doi: 10.1111/j.15372995.2010.02757.x
Asian J Transfus Sci. 2010 Jan;4(1):25-7. doi: 10.4103/09736247.59387

Problems of Inappropriate Use

SHOT Report
2012

Health risk associated with transfusion

Cost of management
> 45% were pathological reaction
Unnecessary pressure on the supply of blood

which may not preventable

5% 4.2% 22.6%
TACOAllo ATR
2.6%
HTR

Risk Vs Benefits of Transfusion

Risk > Benefit

Benefit > Risk

Hb (g/dL)

Why not transfuse?

Reversible
in short term

7 8 9 10 11 12 13
Why transfuse?

Additional factors in comprom

of oxygen transport
Individual patient
factors determine

Summary
Transfusion is a live tissue transplantation
Transfusion should not be dictated by lab values
alone but should also be based on the patients
clinical status
Determine the trigger and dose to be
administered

Give blood when it is really

necessary
Give the patient only what is
needed

Thank you