Blood and Blood

Component Therapy
Dr Rosinni Wong
Department of Anaesthesia and Intensive
Care
Prince of Wales Hospital

23/6/2020
Topics to be covered …
 Blood grouping and cross-matching
 Blood component therapy
 Complications of blood transfusion
 Case Scenarios
Tests for Donated Blood
 Tests
 ABO, Rh blood group
 Infections
 HIV antibody
 HBsAg
 HCV antibody
 HLTV antibody
 Syphilis
 CMV
 Bacterial surveillance
Blood Grouping and
Crossmatch
Blood Group Systems

 ABO system
 Rhesus system
 Other blood groups
 MN, Lutheran, Kell, Duffy, Kidd ….
”Blood typing”
ABO Blood Groups
Blood Red cells have Plasma contains
group

O Neither A nor B Both anti-A and

antigen anti-B Ab

A A antigen Anti-B Ab
B B antigen Anti-A Ab
AB Both A and B antigen Neither anti-A
nor anti-B Ab

 anti-A and anti-B are naturally occurring IgM

Rhesus system
 Many types of Rhesus antigen identified
 RhD Ag is the most antigenic
 Rh positive
 RBC having D antigen
 Rh negative
 RBC without D antigen
 Anti-RhD Ab are IgG
Compatibility testing
 Major complications
 incompatibility between donor’s red cells and
antibodies in recipient’s plasma
 Three procedures
 Blood typing
 Antibody screen
 Cross-match
ABO/ Rhesus typing
 Recipient RBC
 Test with commercially
available anti-A and anti-B Ab
 Test with commercially
available anti-D Ab
Antibody Screening
 Recipient’s serum
 Test with commercially
available RBCs
 Indirect antiglobulin
test
 Use Coomb’s reagent
(antihuman globulin)
Cross-matching
 ‘trial transfusion’
 Recipient’s serum + donor’s RBCs
 Indirect antiglobulin crossmatch
 Takes 30-45 minutes
 Vs Type & screen: 5 min

 Immediate spin crossmatch

 Computer crossmatch
Is Crossmatch Really Necessary?
Compatible
 ABO transfusion
 ABO Rh typing 99.4%
 ABO Rh typing + Ab screen 99.8%
 Crossmatch 99.94%

99.95%
No 100% safety

1 in 10000 incompatible
if X-match is not done
 Blood and blood
component therapy
When should we use
them?
Blood & Blood Components
 What do the blood/blood components
contain?
 What are their functions?
 What are the tests/parameters?
 What is the normal range?
 How low is low that triggers the
transfusion?
Red Cells
Oxygen Supply & Demand
 Normal oxygen consumption :
250ml/min
 Oxygen delivery
 Oxygen flux (DO2)
= Cardiac Output (CO) x Oxygen Content
= 5L/min x 20ml/dL
= 1000ml/min
 Oxygen Content
= (Hgb x 1.39) x O2 saturation + PaO2(0.003)
= 20ml/dL
 Tolerance of anemia
 Maintenance of intravascular volume
 Ability to increase cardiac output
 Adaptive changes that increase oxygen
delivery
Oxygen dissociation curve and 2,3
2,3 diphosphoglycerate

DPG
Transfusion requirements in critical
care (TRICC)
 Restrictive transfusion
 Hb 7-9 g/dL
 Liberal transfusion
 Hb 10-12 g/dL
 30-day mortality
 18.7 % vs 23.3% (P= 0.11)
 significant cardiac disease
20.5% vs 22.9% (P=0.69)
 APACHE II <20
8.7 vs. 16.1 %, (P=0.03)
 Less than 55 years old
5.7% vs 13.0% (P=0.02)

NEJM 340(6):409-417
Hb - Transfusion trigger
 Hb >10g/dL
 Transfusion generally not required
 Hb 7-10g/dL
 Acute/chronic blood loss, ongoing blood loss
 Age, cardiorespiratory status, intravascular volume
 Signs of inadequate perfusion
 Risks of transfusion
 Considerations in ischemic heart disease
 Hb < 7g/dL
 Transfusion usually required
 Hb < 5g/dL
 Transfusion essential
How much to give?
 Packed cells (250-320ml)
 4-5ml/kg to raise Hb 1g/dL 
smaller volume than WB
 Whole blood (350-450ml)
 8-10ml/kg to raise Hb 1g/dL

 Complete transfusion
in 4 hours
 Storage: 2-6 oC
 Shelf life
 Packed cells: 42 days
 Whole blood: 35 days
Platelets
Platelet Concentrates
 Platelets separated from
a single unit of whole
blood
 suspended in a small
amount of the original
plasma

 Volume: 40-60ml

 Shelf life: 5 days at 20-

24°C
 Agitated gently and
continuously on a
platelet shaker during
storage

 ABO compatible
platelets preferable
Platelet Concentrates
 1 unit of platelets increases platelet count
5-10 x 10^9 units in 70kg adult

 1 unit / 10kg BW  increase by 40

Blood bank guideline for Plt
transfusion indications
 <Platelet <10 x 10^9/L in stable patients (usually not
indicated in ITP, SLE, TTP, HUS)
 Platelet <20 x 10^9/L in patients with fever or sepsis
 Platelet <50 x 10^9/L with diffuse microvascular/mucosal
bleeding, major bleeding or before invasive procedures
 Platelet <100 x 10^9/L with retinal or CNS bleeding/surgery
or active bleeding in postcardiompulmonary bypass
 Platelet <50 x 10^9 in stable premature neonates or <100
x 10^9 in sick premature neonates
 Suspected platelet dysfunction with active bleeding or
invasive procedures
 Suspected platelet deficiency with severe active bleeding or
following massive transfusion
Platelet Concentrates
 Prophylactic platelet transfusion is
ineffective and not indicated in
 ITP
 TTP
 Heparin-induced thrombocytopenia
 Use only when these are associated with
haemorrhage
Fresh Frozen Plasma
FFP
 Separated and frozen within 8hrs after
collection of whole blood
 Contains all coagulation factors
 Including labile factors V & VIII
 Volume: 200-250 ml
 Shelf life: 12 months at < -30°C
 ABO compatibility essential
FFP
 Dose: 10-15ml/kg
 Increase coagulation
factors by 30%
 Thawed before
administration
 Once thawed
 Infuse immediately, or
 Stored at 2-6°C for up
to 24 hours
 Complete infusion in 4
hours
Indications for FFP
transfusion
 Urgent reversal of anticoagulation
 Microvascular bleeding in the presence of
elevated (>1.5 times normal) PT or APTT
 Coagulopathy after massive transfusion
 Coagulation factor deficiency (when
specific concentrates are unavailable)
 DIC with bleeding
Cryoprecipitate
Cryoprecipitate
 Prepared by:
 Thawing fresh frozen plasma between 1-6°C
 Recovery the precipitate
 The precipitate is then refrozen
 Factor VIII, Factor XIII, vwF, fibrinogen and
fibronectin
 Volume: 10-40ml
 Shelf life: 12 months at -25°C
 ABO compatible products should be used
Indications for Cryoprecipitate
Transfusion
 Bleeding due to hypofibrinogenemia or
dysfibrinogenemia
 DIC with fibrinogen and FVIII depletion
 Prophylaxis or treatment of significant FXIII
deficiency
 1-1.5u / 10kg BW
Selection of plasma products
Recipient ABO blood group of plasma for
ABO blood
group
transfusion

Unknown AB (if required urgently)

O O or A or B or AB

A A or AB

B B or AB

AB AB
Safe Administration of Blood
 Correct patient
identity
 Blood taking
 Blood processing
 Before transfusion
 Check the package
 Correct method of
storage
Administration of Blood Products
 170-260 m filter
Interaction with other IVF
 0.9% NaCl, plasmalyte, gelofusin can be
infused with blood
 Most other commonly used solutions are
not compatible with blood
 D5
 Haemolysis due to hypontonicity
 Lactated ringers/Haemaccel
 Calcium leads to clotting
Complications of
Blood Transfusion
 Incompatibility

 Disease transmission

 Storage lesion
WHO guidelines
 Haemolytic
 Major incompatability
 Delayed haemolysis
 Non-immune mediated
 Physical – infusion under pressure, hypotonic saline,
mechanical trauma
 Thermal – excess heating
 Non-haemolytic
 Febrile reaction
 Allergic reaction
 Sepsis/bacterial contamination
 TRALI
 TACO
 GVHD
Haemolytic Reactions
 Acute haemolytic reaction
 1:12,000-77,000
 ABO incompatibility, mediated by IgM

 Fever, chills, SOB, chest pain, hemolysis,

hemoglobinuria, MODS, DIC, death

 Mx

 Stop further transfusion

 Disconnect entire iv set with blood and send to blood
bank
 Assess & resuscitate/ ABC
 Keep iv patent
 Check blood label, patient ID, blood form
 Trasnfusion reaction workup (XM, Ab screen, DAT)
 CBP, RFT, clotting, LDH, haptoglobin, bilirubin, urine Hb
 Organ support – BP, renal blood flow, rx of DIC,
coagulopathy
Haemolytic Reactions
 Delayed haemolytic reaction
 1:4,000-9,000
 Previously sensitized patients with low IgG titre

 Rh and Kidd systems

 Hemolysis a few days (2-21 days) after blood

transfusion
 Mx:

 Type and screen

 Transfusion with compatible blood
Non-haemolytic Reactions
 Febrile non-hemolytic transfusion reactions
(FNHTR)
 1:100
 Ig against donor WCC and platelets

 Common especially in multiparous women, or those

who have been transfused on multiple occasions

 Fever, chills

 Mx

 Exclude acute haemolysis, bacterial contamination

 Anti-pyretics
 Slow down infusion
 Use leukocyte-reduced blood products
 Premed with hydrocortisone/ anti-pyretic
Non-haemolytic Reactions
 Anaphylaxis
 Congenital IgA deficiency, high titre of Ig to IgA
 Severe allergic reaction/ Type 1 hypersensitivity

 Cardiovascular collapse, bronchospasm, urticaria

 Mx:

 ABC with organ support

 Adrenaline, steroid, antihistamine
 Organ support
 Saline–washed RBCs
Non-haemolytic Reactions
 Allergic reactions
 Very common, 1-3% of plasma transfusion
 Donor plasma proteins react with recipient’s mast

cells
 Urticaria, itching

 Mx

 Rule out anaphylaxis

 Anti-histamine, +/- steroid
 Saline–washed RBCs in frequent or severe cases
 Slower infusion rate
Non-haemolytic Reactions
 Transfusion-related acute lung injury
 1:5000 – 1:10000 plasma containing blood products
 Donor anti-leucocyte Ab reacts with recipient WCC in

pulmonary vasculature
 Acute respiratory distress < 6 hours after transfusion

 Hypoxemia, bilateral lung infiltrates, hypotension,

fever
 80% improve rapidly within 48h, 5-10% mortality

 Mx

 Organ support
Non-haemolytic Reactions
 TAGvHD
 rare
 transfused immunocompetent lymphocytes directed

against an immunocompromised host

 Skin (rash), liver (hepatitis), GIT (diarrhoea)

 Mx

 Irradiated RBC and platelets

 Immunomodulatory effect
 Due to exposure to WBC
 Increase risk of recurrence of cancers

 Increase risk of post-operative infection

Serious Acute Transfusion
Rx
 Acute hemolytic transfusion reaction
 Anaphylaxis
 Sepsis
 TRALI
Disease transmission
 Bacterial contamination
 CMV, Hepatitis B, Hepatitis C, HIV, HTLV
 Malaria
 Syphilis
 Human Parvovirus B19
 ? vCJD
Crit Care Med 2006 Vol. 34, No. 5 (Suppl.)
Storage lesion
Storage lesion - Biochemical
 Acidosis due to lactate, acidic preservative,
CO2 > Metabolic acidosis
 Hyperkalemia
 Hypocalcaemia
 Citrate toxicity
 Decreased ATP > change in rbc shape and
rigidity
 Glucose
Storage lesion - Functional
 RBCs
 impaired O2 delivery
 spherical and fragile

 Platelets
 after a few days, most become non functional
 Clotting factors
 Heat labile factors especially V and VIII (after 21
days, only 50% and 30% remain)
Complications of transfusion
 Storage lesion
 Hypothermia
 Dilutional thrombocytopenia and coagulopathy
 Fluid overload
 Microaggregates
Case Scenarios
Case 1
 35/F
 Chronic menorrhagia due to uterine polyp
 Plan for hysteroscopic polypectomy
 Pre-operative assessment
 Hb 7, on Fe supplement
 Otherwise healthy and asymptomatic
 Would you transfuse her for the operation?
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Case 2
 40/M
 RTA victim with polytrauma
 BP 90/50 HR 140 after 4L of crystalloid
 Hb 5
 Will you transfuse?
 What type of blood products?

 When XM is not available, will you give

compatible blood products?
 Unmatched blood
 Group O neg
 Group O pos if O neg
blood is not available

 Packed cells
preferable to whole
blood
 Significant Anti-A and
Anti-B in Group O
plasma
Goal of therapy during blood
loss
 Maintenance of intravascular volume
 Maintenance of oxygen carrying capacity
 Maintenance of coagulation
 Maintenance of other functions
 Principle of fluid therapy
 Replenish intravascular volume
 Crystalloids : NS, LR (3:1 ratio)
 Colloids: gelofusine, hetastarch (Voluven), haemacel
Massive Transfusion
 Transfusion of > 1 total blood volume within 24
hours
 Consider metabolic complications
 Hypocalcemia
 Hypothermia
 Hyperkalemia
 Acidosis
 Dilutional thrombocytopenia
 Dilutional coagulopathy
 Triad of hypothermia, acidosis, coagulopathy
Case 3
 70/M
 Bleeding DU, post endoscopic hemostatsis
 Hb 6, transfusion is in progress
 He develops fever and chills during
transfusion of the second unit of blood
 What are the differential diagnosis?
 DDx
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