BLOOD IS VITAL TO LIFE ,OR WE CAN SAY BLOOD IS LIFE.
In INDIA blood transfusion was first started in School Of Tropical medicine. Calcutta,1939, with out any scope for group matching.
As this procedure was unscientific a committee was formed for establishment of blood bank in Calcutta.
Ultimately a small blood bank was started in the dept of Serology, School Of Tropical Medicine named as RED CROSS BLOOD BANK.
Later it was shifted to Maniktala as Central Blood bank.
Pundit Jawhar Lal Nehru donated blood in Calcutta in 1946.
• In spite of dynamic progress in the field medical science, the life saving role of blood is yet with out parallel, even in the 21st century.
• Blood is still the most essential factor in saving a life.
• In INDIA total requirement of blood is approximately 80,00,000.units per year, where as its collection from voluntary donors does not exceed a total of 50,00,000units even after almost 60 years of independence.
Contd.
• In a statistical study it is seen that total no of blood donation in
West Bengal- 713535 (Vol. 85.71%) Bihar – 47863 (Vol. 22.74%)
Jharkhand --- 73238 (Vol. 33.13%) Uttar Pradesh- 394699 (Vol. 17.3%)
Maharashtra- 377110 (Vol. 86.36%)
Preservation and storage of Blood
Since 1978 citrate-phosphate-dextrose with adenine (CPDA-1) is used as blood preservative for
35 days at 2-40C.
Action of ingredients of anticoagulant solution.
Citrate Prevents coagulation by chelating calcium
Sodium di-phospate
Prevents fall in pH
GlucoseSupports ATP
generation by glycolytic pathways
AdenineSynthesizes ATP,
increases level of ATP, extends the self life of RBC to 42 days.
Action of ingredients of anticoagulant solution.- Blood pH on day of collection is 7.5
and on 35th day become 6.84.- A fall in pH in the stored blood
results in a decrease in red cell 2, 3-DPG level, which results in increase in hemoglobin-oxygen affinity. CPDA-1 maintains adequate levels of 2,3-DPG for 10 -14 days.
- During storage Na+ and K+ leak through the red cell membrane rapidly. K+ loss is greater than Na+ gain during storage.
Biochemical changes in stored blood
Characteristics Whole blood RBC conc.
Days of storage 0 35 0 35
% viable cells (24 hrs after transfusion)
100 79 100 71
pH (Measured at 370C)
7.55 6.98 7.60 6.71
Biochemical changes in stored blood
Characteristics Whole blood RBC
2, 3-DPG (% initial value)
100 <10 100 <10
Plasma K (m.mol/l) 5.1 27.3 4.2 78.5
Plasma Na (m.mol/l)
169 155 111
Plasma Hb (mg/l) 78 461 82 658
Transfusion ReactionsReaction Acute
(within 24 hours)
Delayed (within days or
monthImmune-Mediated
Haemolytic Febrile non hemolytic Allergic anaphylactic TR-acute lung injury.
Haemolytic Alloimmunization Post transfusion purpuraGraft-Vs-host disease
Non-Immune Mediated
Bacterial contaminationCirculatory overload hyperkalemia
Hepatitis B & C HIV 1&2 Syphilis Malaria Iron over load
Inspection of bloodBlood should be inspected before transfusion for possible bacterial contamination, haemolysis, visible clots, brown or red plasma. Plasma with a green hue
should not to be rejected because this is caused by exposure of bilirubin pigment to the light.
Yersinia enterocolitica can grow at 40C and the blood is haemolysed.
Importance of component separation
Separation of blood into component allows optimal survival of each constituentsComponent separation allows transfusion of only specific desired component to the patientTransfusion of only the specific constituent of the blood avoids the use of unnecessary component By using blood components several patient can be treated with the blood from one donor
Blood Components (cellular & plasma) & Plasma Derivatives
Cellular components• Red cell concentrate• Leucocytes-reduced red cells• Platelet concentrates• Leucocytes-reduced platelet concentrates• Platelet Apheresis• Granulocytes, Apheresis
Contd.Plasma Components
• Fresh frozen plasma• Single donor plasma• Cryoprecipitate• Cryo-poor plasma
Plasma derivatives• Albumin 5% & 25%• Plasma protein fractions• Factor viii concentrate• Immunoglobulin• Fibrinogen• Other coagulation factors
Preparation of blood component is possible due to
Multiple Poly Vinyl Chloride (PVC) pack systemRefrigerated centrifugeDifferent specific gravity of cellular components◦Red cells spg. 1.08-1.09◦Platelet spg. 1.03-1.04◦Plasma spg. 1.02-1.03Due to different specific gravity of cellular components,
they can be separated by centrifuging at diff g for diff time.
Centrifugation for blood component preparation
The components are prepared by centrifuging at diff relative centrifugal force at diff time.
Relative Centrifugal Force in g=118 x10-7 x r x N2
Precautions to be observed in preparing components
In collection of blood• proper selection of donor• Clean & aseptic venepuncture site to minimize bacterial contamination• Clean venepuncture with minimum tissue trauma and free flow of blood• The flow of blood should be uninterrupted and continuous. If any unit takes
more than 8 minutes to draw, it is not suitable for preparation of blood components.
• A correct amount of blood proportionate to anti coagulant should be collected in primary bag that has satellite bags attached with integral tubing.
Contd.• Monitor the collection of blood with automatic mixer which is used for
collecting the desired amount of blood and mixing the blood with anticoagulant
• If platelets are to be harvested the blood bag should be kept at room temperature 20-240C until platelets are separated. Platelets should be separated within 6 hours from the time of collection of blood.
• Triple packs system with two attached bags makes it possible to make red cells, platelet concentrate and fresh frozen plasma. While quad packs system with three attached bags are used for preparing red cells, platelets concentrate , cryoprecipitate (factor viii) and cryo-poor plasma. Double bags are used making red cells and Platelet rich plasma only.
Blood Component Separation centrifuge centrifuge at 20o freeze -700c Whole blood
pl.rich plasma pl.poor plasma
PRBC platelet FFP cryo poor plasma
frozen RBC leuco poorRBC cryoprecipitate
Whole Blood
Whole blood contains 450+63 ml or 350+49 ml of blood plus anticoagulant solution. The anticoagulant used is CPDA-1.
Whole blood has a hematocrit of 30-40 percent. Minimum 70% of transfused red cells should survive in the recipient’s circulation 24 hrs after transfusion. Stored blood has no functional platelets and no labile coagulation factors V and VIII.
Preparation of Red Blood Cell Concentrates
Red blood cells are prepared by removing most of the plasma from a unit of fresh blood.
Red blood cells preparations are:◦Sedimented red cells: They have a PCV of 60-70%, 30
% of plasma & all original leucocytes and platelets. Kept at 2-60C.
◦Centrifuged red cells: They have a PCV of 70-80 percent, 15 % of plasma and all original leucocytes and platelets. Kept at 2-60C.
◦Red cells with additive (Adsol or SAG-M): They have PCV of 50-60 Percent, minimum plasma and all leucocytes and platelets. Usually kept at 2-40C.
Leukocytes-Reduced Blood Components
Leukocytes in blood components can cause:– Non hemolytic febrile transfusion reactions (NHFTR)– Human leukocyte antigen (HLA) alloimmunisation.– Transfusion of Leukotropic viruses eg. CMV, EBV, HTLV1.– Transfusion related GVHD– Transfusion related acute lung injury (TRALI)– Transfusion related immunosuppression.
Contd.
Cytokines are generated by leukocytes, even at 2-60C but to a much greater extent at 20-240C. Cytokine level rise in direct proportion to the number of leukocyte. Hence leuko-reduction before storage in blood bank is much better than post storage bed side leuko-reduction . Reducing the leukocyte content <5x106 in one unit of RBCs prevents non hemolytic febrile transfusion reactions (NHFTR) and HLA alloimmunisation or transmission of CMV.
Methods of Preparation of Leukocytes-Reduced Red Cells
Centrifugation and removing of Buffy coat Filtration Washing of red cells with saline Freezing and thawing of red cells
leuko-reduction can be done at three diff points
1. Prestorage leuko-reduction 2. Post storage leuko-reduction 3. Bedside filtration
Impact of pre-storage leuko-reduction
Results from pre-storage Potential patient benefit
leuko-reduction ◦Cytokine production is Decrease in NHFTRs
reduced or eliminated
◦White cells are removed Decrease alloimmunizationbefore fragmentation Decrease virus transmission
◦Tumor metastasis are Prevent immunomodulationreduced .
Preparation of Platelet Rich Plasma & Platelet Rich Concentrate
Are prepared from • 450 ml of fresh blood by centrifugation or
Aphaeresis.• A unit of platelet concentrate prepared from
450 ml of fresh blood contains:– Plasma vol. 40-70ml.– Platelet yield 5.5x1010
– WBC ≥108
– RBC traces to 0.5ml.– pH 6.0 or more
Calculation of Platelet Yield– Number of platelet in blood=
platelet per mm3 x1000 x vol. of blood (ml)– Number of platelet in PRP =
platelet per mm3 x 1000 x vol. of PRP (ml.)– Number of platelet in P.C. =
platelet per mm3 x 1000 x vol. of P.C. (ml.) Calculation:– % of platelet yield in PRP=
Number of platelet in PRP x100/ Number of platelet in blood– % of platelet yield in P.C.=
Number of platelet in P.C. x100/ Number of platelet in PRP
Precaution and storagepH should never fall below 6. A decline in pH causes◦Changes in shape of platelets from disc to sphere◦Pseudopod formation◦Release of platelets granules
The above changes are responsible for low recovery and poor survival of platelets in vivo.
Agitation during storage helps the exchange of gases, maintenances of pH, & reduce formation of platelet aggregates.
Granulocyte ConcentratesGranulocyte concentrates prepared by
Single donor unitLeukapheresis by blood cell separators
As the specific gravity of red cells and granulocytes is very similar, the separation of granulocytes by centrifugation is not satisfactory. Leukapheresis is a better method.
Granulocytes can be stored at 20-240C but they should be used within 8 hrs. & not later than 24 hrs from blood collection.
Fresh Frozen Plasma (FFP)It contains all coagulation factors & great care must be taken during
collection of blood , freezing and thawing to preserve their activity.Collection of blood :1. Blood should be collected le by a clean, single venepuncture.2. Flow of blood should be rapid and constant.3. Total time taken to collect 450 ml of blood should not be more than
8 minutes.The most labile coagulation factors are preserved for one
yr. if FFP is kept at -300C or below. If FFP is not used within one yr. it is redesignated as Single Donor Plasma which can be kept further for 4 yrs at -300C or below.
The FFP should be administered as soon as possible after thawing, and in any event within 12 hrs. if kept at 2-60C.
Cryoprecipitate Cryoprecipitate are precipitated proteins of plasma rich in Factor VIII
and fibrinogen, obtained from a single unit of fresh plasma ( approximately 200 ml.) by rapid freezing within 6 hrs of collection.
Factors improve the yield of Factor VIII in Cryoprecipitate1. Clean single venepuncture at first attempt2. Rapid flow of blood, donation of blood (450ml) obtained in less
than 8-10 mins should be used3. Adequate mixing of blood and anticoagulant4. Rapid freezing of plasma as soon as possible after collection in any
case within 6-8 hrs after collection as done for preparing FFP.5. Rapid thaw at 40C in circulating water bath.
Storage and shelf life of Cryoprecipitate: One yr at -300C or below.After reconstitution Cryoprecipitate should be kept at 2-60C and administered within 4 hrs.
Single Donor Plasma
Single donor plasma can be prepared by separating it from red cells any time up to 5 days after the expiration of the whole blood unit. When stored at -200C or lower, single donor plasma may be kept up to 5 yrs.
A prolonged pre separation storage period increases its contents of potassium & ammonia.
It has no labile coagulation activity.
Cryoprecipitate Poor Plasma
• It is a by-product of cryoprecipitate preparation.
• It lacks labile clotting factors V and VIII and fibrinogen.
• It contains adequate levels of stable clotting factors II, VII, IX & X.
• It is frozen and stored at -200C or lower temperature for 5 yrs.
Indications, Contraindications & Complications of Diff Blood Components
BLOOD TYPES Fresh BloodFresh BloodWhole blood or RBC
concentrates less less than 12-24 hours oldthan 12-24 hours old form the time of collection are considered as Fresh Blood
• Whole Blood • Blood after 24 hours
of collection to 35 days are considered as Whole Blood (without platelet and labile clotting factor)
Fresh blood
In new born exchange transfusion
open heart surgery HyperkalemiaRenal failure
One unit increases 0.8 gm% hemoglobin in adult
Disadvantages of Fresh blood transfusion 1. Chance of transfusion of
cytomegalovirus virus, Human T- Cell Lymphotropic virus type I & II, E.B Virus, Treponema pallidum
2. Non –hemolytic febrile transfusion reaction
3. Transfusion Related Acute Lung Injury (TRALI) results pulmonary oedema
Cytomegalovirus (CMV)CMV is a common human pathogen and present in sub clinical stage in 90 %
adults. - It is the common cause of
congenital defects eg. Microcephaly, Intra cerebral calcification, mental retardation, unilateral or bilateral hearing loss.
Viruses are shed in most of the body fluids.
It infect the mononuclear leucocytes.
Whole blood Blood after 24 hours of collection
to 35 days are considered as Whole Blood (without platelet and
labile clotting factor)1.Symptomatic decrease in oxygen –
carrying capacity combined with hypovolemia.
2.More than 30% blood loss in acute haemorrhage.
3.Anticipated surgical blood loss more than 1 litre .
4.Source of protein with oncotic property.
5.Source of Non-labile coagulation factors.
6.Inoperative blood loss more than 15%.
Indication
Whole blood 1.Less oxygen carrying capacity
and more potassium accumulation.
2.Low level of 2, 3 –di- phosphoglycerate which is important in premature neonates, patient with impaired cardiac function, haemorrhagic shock, respiratory distress syndrome.
3.Develop C.C.F in severe anemic patient.
4.Contraindicated in multiple transfusion
Disadvantages
Whole blood
1.Dilutional thrombocytopenia
2. C.C.F
Complication
Red blood cell concentrate (packed Red Cell) are prepared by
removing most of the plasma from a unit of whole blood.
1.Urgent operation with haemoglobin less than 10 gm%2.Anaemia associated with cardiac failure.3.Haemoglobin less than 6 gm%4.Approaching delivery and haemoglobin less than 7 gm%5.Liberal guideline in thalassaemia major 6.Anticipated surgical blood loss more than one litre
Indication:
contra-indication
RBC concentrate1.Chronic renal failure2.Pre-operative transfusion
to raise hemoglobin above 10gm%
3.Nutritional Anaemia 4.To enhance general well
being, promote healing, prevent infection
Platelet Concentrate
(Production of platelets are approx. 40000/microlitre/day)
1 unit platelet increases 7000/microlitre platelet count in adult, 80000/microlitre in infants, 20000 /microlitre in
Child of 18 kg body wt.
Platelet Concentrate (Production of platelets are approx.
40000/microlitre/day).1. Count less than 5000/microlitre
regardless clinical condition2. Count is around 20000/microlitre with
thrombocytopenic bleeding or increase risk of bleeding in acute leukaemia or chemotherapy
3. Count is around 60000/microlitre with DIC or before major surgery.
Indication:
Administration of ABO incompatible platelet is an acceptable transfusion practice, but not Rh incompatible platelet.
Platelet Concentrate
1.Chill, Fever, Allergic reaction
2.Infusion of Bacteria 3.Alloimmunisation4.Platelet refractory state5.Graft vs. host disease
Complication
1.ITP 2.TTP3.Heparin induced
thrombocytopenia4.No role in routine open
heart surgery5.Invasive procedure where
count is more than 50000/microlitre
6.Bleeding unrelated to decrease platelet number and function.
Platelet concentrate
contra-indication
Fresh frozen plasma
1.Actively bleeding and multiple coagulation factor deficiency
2.Liver Diseases 3.DIC4.Coagulopathy in massive
transfusion5.TTP6.Von Willebrand disease
Indication
contra-indication
1.Should not be used as blood volume expander
2.Hypoproteinaemia3.When prothrombine time
is less than 18 second4.Source of immunoglobin
Fresh frozen plasma
Limitations1.Components must be
prepared within 6 hours from collection time
2.Needs costly instruments and infrastructures and specially trained personnel
Plasma Derivatives & Plasma Substitutes
Plasma protein solutions Plasma protein solutions are prepared from
pooled plasma after removal of factor viii conc., fibrinogen & immunoglobulin
– Albumin preparation • Albumin 5% soln.• Albumin 25% soln.
contain 96% alb & 4% globulin• Plasma protein fraction (PPF) 5% soln.
Contain 83% alb. & 17% globulin
Characteristics of Albumin Preparation
The 5% soln. are osmotically and oncotically equivalent to plasma, 25 % soln. is five times that of plasma
Products are heated and chemically treated to reduce the risk of viral disease transmission mainly the viruses that have lipid envelope eg.HIV1 & 2, Hepatitis B&C, HTLV1&2
Shelf life depends on the storage temperature—◦room temp----3yrs
Indications5% albumin & PPF◦Blood volume expansion & colloid replacement◦Hypoproteinemia following burn & extensive surgery◦The replacement fluid in therapeutic plasma
exchange◦Hemorrhagic hypovolemic shock◦Retroperitoneal surgery in which large vol. of
protein rich fluid may pool in bowel
◦25% albumin Severe Hypoproteinemia in acute nephrotic syndrome & acute liver
disease Hyperbillirubinemia in the new born Toxemia in pregnancy
Adverse Effect & Contraindication
• Adverse effects– Urticaria and anaphylactoid reactions– Circulatory overload– Febrile reactions– Hypotension due to vasoactive substances in
plasma– Contraindications• Hypoproteinemia in malnutrition• Chronic Nephrotic syndrome• Cirrhosis of liver
Factor VIII Concentrate Preparations available
◦ Factor viii prepared from large pools of plasma is sterile , lyophilized
◦ Commercially prepared by recombinant DNA technology
◦ Storage Freeze dried products are stored at 2-60C
Indications◦ Hemophilia A ◦ Hemophilia A with low levels of inhibitors of factor viii◦ Von-Willibrand disease
Immunoglobulin preparation
• Immunoglobulin for IM use:A concentrated solution of the IgG
component of plasma prepared from large pools plasma of donors containing antibodies against infectious agents
• Indication– Congenital Hypogammaglobinemia– Persons exposed to diseases like Hepatitis A or
Measles
• Immunoglobulin for IV use:– Indications
• Idiopathic autoimmune thrombocytopenic purpura• Treatment of immune deficiency states• Hypogammaglobinemia• Myasthenia gravis• HIV related disease
Contd.• Hyper immune Globulin
Used for prevention of diseases like Hepatitis B, Varicella Zoster, Rabies, mumps & others
• Anti-Rh (D) Immunoglobulin (anti-D RHIG)prepared from plasma containing high level of Anti-Rh D antibody from previously immunized persons.
Indication: To prevent Rh (D) negative mother from Rh immunization
who is pregnant with Rh. (D) positive infant.