Académique Documents
Professionnel Documents
Culture Documents
Other Components :-
1. Granulocytes
2. Coagulation Factor Concentrates
3. Immunoglobulins
Whole Blood
Whole blood collected from blood donor in CPDA-
1 Solution
399 ml ( 350 blood + 49 ml CPDA-1) and 513 ml
( 450 blood + 63 ml CPDA-1)
Indications :
Red cell replacement in acute blood loss with
hypovolaemia
Exchange transfusion
Patients needing red cell transfusions where red cell
concentrates or suspensions are not available
PRBC
Hematocrit of 65% to 80% and a usual volume
between 225 mL and 350 mL.
Each unit of RBCs or Whole Blood contains enough
hemoglobin to increase the hemoglobin
concentration in an average-sized adult by
approximately 1 g/dL (increase hematocrit by
3%).
Iron overload is a complication of chronic RBC
transfusion therapy. Each transfusion contributes
approximately 250 mg of iron
Ref : Circular of Information for the Use of Human Blood and Blood - AABB
Physiology of PRBC Transfusion
DO=cardiac output CaO
Recommendations
Recommendations
However, there was some uncertainty about the risk for perioperative myocardial infarction associated with a restrictive transfusion
strategy. There was moderate heterogeneity between the results of the 2 major trials, and they were not large enough to precisely define
the risks and benefits of transfusion in this setting.
Question 3
Recommendations
The AABB cannot recommend for or against a liberal or restrictive RBC transfusion
threshold. Further research is needed to determine the optimal threshold.
Recommendations
Ref : Carless PA, Henry DA, Carson JL, Hebert PP, McClelland B, Ker K. Transfusion thresholds and other strategies for guiding allogeneic red blood cell
transfusion. Cochrane Database Syst Rev. 2010;(10):CD002042
Transfusion in Thalassemia
Thalassemia major hypertransfusion strategy is suggested
Hypertransfusion regimen is designed to
maintain a relatively stable hemoglobin level
partially suppress ineffective erythropoiesis.
Platelet Alloimmunization
Nonimmune events may also contribute to reduced platelet survival.
Splenomegaly
sepsis
Fever
intravascular devices
DIC
His research was put into use during the First World War
Preservative solutions
The first anticoagulant preservative was citrate-glucose solution
The next important development occurred during the Second World
War when acidifieditrate dextrose (ACD) solution was introduced
1957 : Citrate-phosphate-dextrose (CPD), which was less acidic than
ACD and maintained 2,3-diphosphoglycerate (2,3-DPG) level better
than in ACD solution. Shelf-life of blood stored in CPD at 2-4 C was
21 day.
In 1978 : CPDA-1. The addition of adenine improved the synthesis of
adenosine triphosphate (ATP) in the stored blood,which prolonged
the storage of blood/red cells at 2-4 C to 35 days.
Additive Solutions : Traditional preservatives were put into use when
whole blood was the major product. With the advent of component
therapy use of red cells increased. Additive solutions provide
nutirents to the RBC for better viability. Addition of such solutions
increases the storage time to 42 days.
Bottle to Bag
In one of the single most influential technical
developments in blood banking, Carl Walter and
W.P. Murphy, Jr., introduce the plastic bag for
blood collection in 1950.
Replacing breakable glass bottles with durable
plastic bags allows for the evolution of a collection
system capable of safe and easy preparation of
multiple blood components from a single unit of
whole blood.
Today blood bags are made of high tensile
strength PVC.
In vitro RBC changes during storage
2,3 BPG concentration After five to six weeks of storage, levels in the RBC
progressively fall toward 10 percent of normal. As a result, the oxyhemoglobin
dissociation curve progressively shifts to the left, resulting in reduced oxygen release
by hemoglobin at any given tissue pO2.
Potassium leakage Potassium is not actively transported back into the RBC
because membrane ATPase is inhibited at 1 to 6C, the temperature range
employed for storage of red cells. The potassium concentration peaks at
approximately 30 to 50 mEq/L in whole blood (90 mEq/L in packed RBC
products), and as high as 70 mEq/L in 28-day-old irradiated blood
Lancet. 1994 . HIV-1/HIV-2 seronegativity in HIV-1 subtype O infected patients. Loussert-Ajaka Iet al.
HIV (Contd.)
Although HIV-1 has had an extremely prominent
role in blood safety, this is not the case for HIV-2.
While there have been thousands of cases of
transfusion transmitted HIV-1 infection, there have
been fewer than 50 such cases attributed to HIV-
2
HIV is inactivated by the purification process used
to produce plasma derivatives such as albumin
and IVIg. There has never been a documented
case of HIV transmission from albumin or immune
globulin preparations.
Hepatitis
Blood transfusion was a major risk factor for acute post
transfusion infectious hepatitis in the past.
The screening of blood donors for historical risk factors,
serologic evidence of hepatitis B infection, and elevated
serum ALT caused a striking reduction in the rates of
non-A, non-B post-transfusion hepatitis, even before
HCV was identified.
The subsequent initiation of donor screening for anti-
HCV antibodies in 1990 has nearly eliminated the risk
of post-transfusion acute HCV infection. The estimated
risk is now less than one in a million per unit transfused
FNHTR
Febrile nonhemolytic transfusion reactions (FNHTRs) are the most
common of all transfusion reactions. They occur in approximately 0.1
to 1 percent of transfusions.
FNHTRs are commonly caused by cytokines that are generated and
accumulate during the storage of blood components
Clinical manifestations of FNHTR occur within one to six hours after
initiation of a transfusion
These include fever, often a chill, occasionally severe rigors, and
sometimes mild dyspnea. The temperature increase is typically in the
range of 1 to 2C.
The major means of preventing FNHTRs is pre-storage leukoreduction
of the product.
Usage of premedications is not recommended.
TRALI
Transfusion Associated ALI is defined as new
acute respiratory distress syndrome (ARDS)
occurring during or within six hours after blood
product administration
RISK FACTORS :-
TRALI has been associated with virtually all blood
products, high-plasma-volume components such as
plasma, apheresis platelet concentrates, and whole
blood have been consistently shown to carry the
greatest risk
female sex and increased parity of the donor
1. Neutrophil sequestration
and priming
2. Neutrophil Activation
Diagnostic Criteria : TRALI
TACO
The possibility of Transfusion-associated
circulatory overload
(TACO) should be considered in any patient who
has respiratory distress or hypertension within six
hours of completing a transfusion.
Patient risk factors include pre-existing cardiac
and possibly renal dysfunction, small stature, low
body weight, extremes of age (eg, <3 years,
>60 years), and hypoalbuminemia, number of
units transfused
TACO vs. TRALI
Unlike TACO, the risk of TRALI is not related to the
volume of the transfusion.
TRALI may occur closer in time to the initiation of the
transfusion (before significant volume is infused)
TRALI is often associated with hypotension, fever, and
transient leukopenia. TRALI is not associated with an
elevated N terminal Pro-BNP (NT Pro-BNP), central
venous pressure, or pulmonary artery wedge pressure.
In TRALI, the ratio of protein in the edema fluid to
plasma is high, reflecting an exudate rather than a
transudate
Hemolytic Transfusion Reactions
Acute HTRs (AHTRs) are usually due to ABO incompatibility, most often the result of clerical or
procedural error
Patterns of hemolysis :
hemolysis of the transfused cells by a host immune response against a foreign (to the recipient) antigen on the
these RBCs.
In some cases, transfusion of plasma-containing antibodies directed against a recipient's RBC antigen leads to
hemolysis of the recipient's RBCs. This is less common primarily because the incompatible donor plasma is
instantly diluted upon transfusion, reducing the strength of the transfused antibodies.
Rarely, both donor and recipient RBCs can be destroyed : hyperhemolytic crisis. The mechanism by which
hemolysis of RBCs lacking the implicated antigen (bystander hemolysis) occurs is not well understood.
Only a small amount of exposure (<1 mL of blood) is required to elicit an antibody response
The abundance of the antigen on the RBC surface also influences the severity of the reaction. Antigen
density varies significantly for different RBC antigens. As an example, ABO antigens are present at
approximately 200,000 to 800,000 per cell, while Kell antigens are present at approximately 3000
to 6000 per cell, a 100-fold difference
Site of RBC destruction (intravascular or extravascular) is determined chiefly by nature of antibody
response. This has clinical implications
Non-immune hemolysis from RBC injury :
Thermal
Osmotic
Mechanical
AHTR
Acute HTR (AHTR) refers to transfusion-associated hemolysis that
occurs during the transfusion or within the first 24 hours after
transfusion.
AHTR is a medical emergency that requires immediate cessation of
the transfusion
An ABO-associated AHTR may be suspected when a patient
develops chills, fever, hypotension, hemoglobinuria, renal failure,
back pain, or signs of disseminated intravascular coagulation (DIC).
The serum or urine may be pink due to the presence of free hemoglobin.
In a patient under anesthesia or in a coma, oozing from venipuncture
sites due to DIC or change in the urine color to red or brown due to
hemoglobinuria
Stop transfusion, Normal saline (avoid RL/ DNS) should be infused
immediately to reduce the risks of hypotension and renal injury.
DHTR
Delayed HTRs (DHTRs) are defined as HTRs that
occur more than 24 hours following transfusion
DHTRs most commonly present one to two weeks
after transfusion of RBCs, although the interval can
range from 3 to 30 days. These reactions are most
commonly due to an amnestic response to a
foreign RBC antigen to which the recipient was
previously exposed. Common routes of previous
exposure include prior transfusions and pregnancy
RBC antigens most commonly responsible for
DHTRs include those of the Kidd or Rh system.
TA GVD
Transfusion-associated graft versus host disease (ta-GVHD) does not occur
after most transfusions because the donor lymphocytes are destroyed by the
recipient's immune system before they can mount a response against the
host. However, this protective response does not occur in two settings:
when the recipient is immunodeficient
when there is a specific type of partial HLA matching between the donor and
recipient.
Ta-GVHD develops 4 to 30 days after blood transfusion.
Patients typically present with fever and rash. Other symptoms include
anorexia, vomiting, abdominal pain, profuse diarrhea, and cough.
Distinguishing transfusion-associated GVHD (ta-GVHD) from transplantation-
associated disease. Ta-GVHD is poorly responsive to any available form of
therapy and is almost always a fatal complication.
Prevention : Irradiation, (?) 4th Generation Leucodepleton
1. Blood Substitutes
For more than 100 years researchers have
pursued the Holy Grail of trauma medicine: a
blood substitute. The ideal blood substitute
would retain all the functions of blood and
none of the transfusion problems associated
with blood.
Blood Substitutes (Contd.)
Research exploring alternatives to blood began
approximately 150 years ago.
Searching for a blood substitute, T. Gaillard Thomas posited
that intravenous infusion of cows milk, a process he
termed lacteal injections, might have the potential to save
lives.
Thomas presented three case studies of moribund patients
into whom he injected about 8 ounces of fresh cows milk. In
these case studies, one patient survived and two died. He
attributed their deaths to other complications unrelated to
the lacteal injections and claimed the injections were safe
provided that fresh milk was used.
1. Blood Substitutes
HEMOGLOBIN SOLUTIONS
Native tetrameric hemoglobin, when removed from the red cell, breaks down into dimers, which are rapidly
cleared by glomerular filtration, resulting in a short vascular half-life.
Furthermore, free hemoglobin has reduced contact with phosphates, causing the P50 curve to shift to the left,
resulting in hemoglobin with a high oxygen affinity and limited oxygen unloading.
Significant renal damage
Three HBOCs that have progressed to Phase II or III clinical trials: HemAssist, PolyHeme, and
Hemopure
Cross linking and Polymerization
PERFLUOROCARBON EMULSIONS
The fundamental difference in O2 transfer by Hb and PFC is that the former binds O2, while the latter
dissolves it.
Oxygen is dissolved in PFCs at a concentration of about 40%50%, which is 20 times higher than the
capacity of water and 2 times higher than plasma.
Their small sizes enable them to easily pass through the vessels occluded in some diseases, where
RBCs cannot pass; hence, their application helps improving the oxygenation rate. An in vitro study
showed that use of PFCs as artificial blood is considerably advantageous in occluded coronary artery
to maintain myocardial function.
Other Experimental approaches
NEW FRONTIERS
Elimination of blood group antigens Enzymatic conversion of A,
B, and AB red cells to group O has been achieved in vitro via the use
of exoglycosidases derived from bacterial sources. This enzymatic
conversion (ECO) technique, if proven to be safe and effective, has
the potential to simplify blood transfusion by eliminating the risk for
ABO-incompatible transfusion errors and creating a more universal
blood inventory.
Ex vivo generation of red cells Limited numbers of viable red
cells can be generated ex vivo in culture systems from CD34+
hematopoietic stem cells.
Sanguis ovis symbolicam quandam facultatem habet cum sanguine Christi, quia
Christus est agnus Dei
Sheeps blood has some symbolic power, like the blood of Christ, for Christ is the Lamb of God.
2. Xenotransfusion
From 2000, because of progress in
xenotransplantation and the need of blood supply,
xenotransfusion is again in th limelight.
Pigs are the best potential donors.
RBC diameters (pig 6 m: human 7.2 m)
The pig blood group AO system is related to the human
ABO system
uniform pig herds in which all animals are of blood
type O already exist
Genetic Modification to further the phenotype and
immunotype can be undertaken
3. Blood Doping
"Blood doping" was banned by the IOC in 1985.
On August 23, 2012 Lance Armstrong was
stripped of his seven Tour de France titles and
banned for life.
More potent for use in blood doping is
Co2+ (administered as Cobalt chloride).
Cobalt chloride has been known to be useful in
treating anemic patients.
Studies have shown that Co2+ induces hypoxia like
responses, the most relevant response being
erythropoiesis.
Cobalt Chloride in Refractory Anemia
The 5 Rights of Transfusion Ensure that the
Right Patient is getting the
Right Product
in the Right Amount
at the Right Rate
at the Right Time
Bonus
Why you wont find a tattoo on
Christiano Ronaldo
Ronaldo, skips the ink so that he can continue to
donate blood. In many countries, a new tattoo
can affect how often a person donates blood,
with a waiting period between six months and
a year employed as a precaution against
cross-contamination and diseases like hepatitis.