II. Blood and Blood II. Blood and Blood ComponentsComponents

Terry Kotrla, MS, MT(ASCP)BBTerry Kotrla, MS, MT(ASCP)BB

Spring 2010Spring 2010

Goals Of Blood CollectionGoals Of Blood Collection

Maintain viability and functionMaintain viability and function Prevent physical changesPrevent physical changes Minimize bacterial contaminationMinimize bacterial contamination

Anticoagulants Preservative Solutions

Anticoagulants prevent blood clottingAnticoagulants prevent blood clotting Preservatives provide nutrients for Preservatives provide nutrients for

cellscells HeparinHeparin

– Rarely if ever used anymoreRarely if ever used anymore– Anticoagulant ONLYAnticoagulant ONLY– Transfuse within 48 hours, preferably 8Transfuse within 48 hours, preferably 8

AnticoagulantsAnticoagulants

CPDCPD CPD-A1CPD-A1

Storage Storage timetime

21 days21 days 35 days35 days

TemperaturTemperaturee

1-6 C1-6 C 1-6 C1-6 C

Slows glycolytic activitySlows glycolytic activity

AdenineAdenine NoneNone Substrate for ATP Substrate for ATP synthesissynthesis

VolumeVolume 450 +/- 10%450 +/- 10%

DextroseDextrose Supports ATP generation by Supports ATP generation by glycolytic pathwayglycolytic pathway

CitrateCitrate Prevents coagulation by binding Prevents coagulation by binding calciumcalcium

Additive SolutionAdditive Solution

Primary bag with satellite bags attached.Primary bag with satellite bags attached. One bag has additive solution (AS)One bag has additive solution (AS) Unit drawn into CPD anticoagulantUnit drawn into CPD anticoagulant

Additive SolutionAdditive Solution Remove platelet rich plasma within 72 Remove platelet rich plasma within 72

hourshours Add additive solution to RBCs, ADSOL, Add additive solution to RBCs, ADSOL,

which consists of:which consists of:– SalineSaline– AdenineAdenine– GlucoseGlucose– MannitolMannitol

Extends storage to 42 daysExtends storage to 42 days Final hematocrit approximately 66%Final hematocrit approximately 66%

Changes Occur During Changes Occur During StorageStorage

Shelf life = expiration dateShelf life = expiration date– At end of expiration must have 75% At end of expiration must have 75%

recoveryrecovery– At least 75% of transfused cells remain At least 75% of transfused cells remain

in circulation 24 hours AFTER in circulation 24 hours AFTER transfusiontransfusion

Storage LesionStorage Lesion Biochemical changes which occur at 1-6CBiochemical changes which occur at 1-6C Affects oxygen dissociation curve, increased Affects oxygen dissociation curve, increased

affinity of hemoglobin for oxygen.affinity of hemoglobin for oxygen.– Low 2,3-DPG, increased OLow 2,3-DPG, increased O22 affinity, less O affinity, less O22

released.released.– pH drops causes 2,3-DPG levels to fallpH drops causes 2,3-DPG levels to fall– Once transfused RBCs regenerate ATP and 2,3-Once transfused RBCs regenerate ATP and 2,3-

DPGDPG Few functional platelets presentFew functional platelets present Viable (living) RBCs decreaseViable (living) RBCs decrease

Plasma hemoglobin

Plasma K+

Viable cells

pH

ATP

2,3-DPG

Plasma Na+

Helps release oxygen from hemoglobin (once transfused, ATP & 2,3-DPG return to normal)

K+Na+

Storage LesionStorage Lesion

Significant for infants and massive Significant for infants and massive transfusion.transfusion.

Other biochemical changesOther biochemical changes– ATP decreasesATP decreases– Potassium increasesPotassium increases– Sodium decreasesSodium decreases– Plasma hemoglobin increasesPlasma hemoglobin increases

Preparation of ComponentsPreparation of Components Collect unit within 15 minutes to prevent Collect unit within 15 minutes to prevent

activation of coagulation systemactivation of coagulation system Draw into closed system – primary bag with Draw into closed system – primary bag with

satellite bags with hermetic seal between.satellite bags with hermetic seal between. If hermetic seal broken transfuse within 24 If hermetic seal broken transfuse within 24

hours if stored at 1-4C, 4 hours if stored at hours if stored at 1-4C, 4 hours if stored at 20-24C20-24C

Preparation of ComponentsPreparation of Components

Centrifuge – light spin, platelets suspendedCentrifuge – light spin, platelets suspended Remove platelet rich plasma (PRP)Remove platelet rich plasma (PRP) Centrifuge PRP heavy spinCentrifuge PRP heavy spin Remove platelet poor plasmaRemove platelet poor plasma Freeze plasma solid within 8 hoursFreeze plasma solid within 8 hours Thaw plasma at 1-4C – precipitate formsThaw plasma at 1-4C – precipitate forms Centrifuge, express plasma leaving Centrifuge, express plasma leaving

cryoprecipitate. Store both at -18Ccryoprecipitate. Store both at -18C RBCs – CPD – 21 days, ADSOL – 42 days – RBCs – CPD – 21 days, ADSOL – 42 days –

1-6C1-6C

Preparation of ComponentsPreparation of Components

Summary – One unit of whole blood Summary – One unit of whole blood can produce:can produce:– Packed RBCsPacked RBCs– Fresh frozen plasma (FFP)Fresh frozen plasma (FFP)– Cryoprecipitate (CRYO)Cryoprecipitate (CRYO)– Single donor plasma (SDP) – cyro removedSingle donor plasma (SDP) – cyro removed– Platelets – terms PC (platelet concentrate) Platelets – terms PC (platelet concentrate)

OR RD PC (random donor platelet OR RD PC (random donor platelet concentrate)concentrate)

Preparation of ComponentsPreparation of Components

Sterile docking device joins tubingSterile docking device joins tubing– Used to add satellite bags to maintain original Used to add satellite bags to maintain original

expiration of componentexpiration of component– May be used to pool componentsMay be used to pool components

Blood Component General Blood Component General InformationInformation

Blood separated into components to Blood separated into components to specifically treat patients with specifically treat patients with product neededproduct needed

Advantages of component separationAdvantages of component separation– Allow optimum survival of each Allow optimum survival of each

componentcomponent– Transfuse only component neededTransfuse only component needed

Blood Component General Blood Component General InformationInformation

Transfusion practiceTransfusion practice– Transfusion requires doctor’s prescriptionTransfusion requires doctor’s prescription– All components MUST be administered All components MUST be administered

through a filterthrough a filter– Infuse quickly, within 4 hoursInfuse quickly, within 4 hours– D (Rh) neg require D neg cellular productsD (Rh) neg require D neg cellular products– ABO identical preferred, ABO compatible ABO identical preferred, ABO compatible

OKOK– ““Universal donor” – RBCs group O, plasma Universal donor” – RBCs group O, plasma

ABAB

Blood Component General Blood Component General InformationInformation

Fresh Whole BloodFresh Whole Blood– Blood not usually available until 12-24 Blood not usually available until 12-24

hourshours– CandidatesCandidates

Newborns needing exchange transfusionNewborns needing exchange transfusion Patients requiring leukoreduced productsPatients requiring leukoreduced products

Blood Component General Blood Component General InformationInformation

Summary of storage temperatures:Summary of storage temperatures:– Liquid RBCs 1-6CLiquid RBCs 1-6C– Platelets, Cryo (thawed) and Platelets, Cryo (thawed) and

granulocytes 20-24C (room granulocytes 20-24C (room temperature)temperature)

– ANY frozen plasma product ≤ -18CANY frozen plasma product ≤ -18C– ANY liquid plasma product EXCEPT Cryo ANY liquid plasma product EXCEPT Cryo

1-6C1-6C

Blood ComponentsBlood Components

CellularCellular– Red blood cell productsRed blood cell products– PlateletsPlatelets– GranulocytesGranulocytes

PlasmaPlasma– FFPFFP– CryoprecipitateCryoprecipitate

Products With Red CellsProducts With Red Cells

Whole BloodWhole Blood Clinical indications for use of WB are extremely

limited. Used for massive transfusion to correct acute

hypovolemia such as in trauma and shock, exchange transfusion.

RARELY used today, platelets non-functional, labile coagulation factors gone.

Must be ABO identical.

Changes in Stored BloodChanges in Stored Blood

Red Blood Cells, Packed Red Blood Cells, Packed (PRBC)(PRBC)

Used to treat symptomatic anemia and routine blood loss during surgery

Hematocrit is approximately 80% for non-additive (CPD), 60% for additive (ADSOL).

Allow WB to sediment or centrifuge WB, remove supernatant plasma.

Leukocyte Reduced Red Cells (LR-Leukocyte Reduced Red Cells (LR-RBC)RBC)

Leukocytes can induce adverse affects during transfusion, primarily febrile, non-hemolytic reactions.

Reactions to cytokines produced by leukocytes in transfused units.

Other explanations to reactions include: immunization of recipient to transfused HLA or granulocyte antigens, micro aggregates and fragmentation of granulocytes.

Historically, indicated only for patients who had 2 or more febrile transfusion reactions, now a commonly ordered, popular component.

“CMV” safe blood, since CMV lives in WBCs. Most blood centers now leukoreduce blood immediately

after collection. Bed side filters are available to leukoreduce products

during transfusion.

Leukocyte ReductionLeukocyte Reduction

Washed Red Blood Cells (W-RBCs)

Washing removes plasma proteins, platelets, WBCs and micro aggregates which may cause febrile or urticarial reactions.

Patient requiring this product is the IgA deficient patient with anti-IgA antibodies.

Prepared by using a machine which washes the cells 3 times with saline to remove and WBCs.

Two types of labels:– Washed RBCs - do not need to QC for WBCs.– Leukocyte Poor WRBCs, QC must be done to guarantee

removal of 85% of WBCs. No longer considered effective method for leukoreduction.

e. Expires 24 hours after unit is entered.

Cell Washer to Prepare Washed Cell Washer to Prepare Washed CellsCells

Frozen BloodFrozen Blood

Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Blood is frozen to preserve: rare types, for autologous transfusion, stock piling blood for military mobilization and/or civilian natural disasters.

Blood is drawn into an anticoagulant preservative.– Plasma is removed and glycerol is added.– After equilibration unit is centrifuged to remove excess

glycerol and frozen. Expiration

– If frozen, 10 years.– After deglycerolization, 24 hours.

Storage temperature– high glycerol -65 C.– low glycerol -120 C, liquid nitrogen.

Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Thaw unit at 37C, thawed RBCs will have high concentration of glycerol.

A solution of glycerol of lesser concentration of the original glycerol is added.

This causes glycerol to come out of the red blood cells slowly to prevent hemolysis of the RBCs.

After a period of equilibration the unit is spun, the solution is removed and a solution with a lower glycerol concentration is added.

This procedure is repeated until all glycerol is removed, more steps are required for the high glycerol stored units.

The unit is then washed.

Rejuvenated Red Blood Cells

A special solution is added to expired RBCs up to 3 days after expiration to restore 2,3-DPG and ATP levels to prestorage values.

Rejuvenated RBCs regain normal characteristics of oxygen transport and delivery and improved post transfusion survival.

Expiration is 24 hours or, if frozen, 10 years

Platelet ProductsPlatelet Products

Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

Used to prevent spontaneous bleeding or stop established bleeding in thrombocytopenic patients.

Prepared from a single unit of whole blood. Due to storage at RT it is the most likely component

to be contaminated with bacteria. Therapeutic dose for adults is 6 to 10 units. Some patients become "refractory" to platelet

therapy. Expiration is 5 days as a single unit, 4 hours if

pooled. Store at 20-24 C (RT) with constant agitation. D negative patients should be transfused with D

negative platelets due to the presence of a small number of RBCs.

Preparation of platelet Preparation of platelet concentrateconcentrate

RBCs PRP

Plasma

Platelet concentrate

Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

One bag from ONE donorOne bag from ONE donor Need 6-10 for therapeutic doseNeed 6-10 for therapeutic dose

Pooling PlateletsPooling Platelets 6-10 units transferred into one bag6-10 units transferred into one bag Expiration = 4 hoursExpiration = 4 hours

Platelets Pheresis, Apheresis Platelet Concentrate, Single Donor Platelet Concentrate (SD-PC)

Used to decrease donor exposure, obtain HLA matched platelets for patients who are refractory to RD-PC or prevent platelet refractoriness from occurring.

Prepared by hemapheresis, stored in two connected bags to maintain viability.

One pheresed unit is equivalent to 6-8 RD-PC. Store at 20-24 C (RT) with agitation for 5 days,

after combining, 24 hours D negative patients should be transfused with D

negative platelets due to the presence of a small number of RBCs

ApheresisApheresis

ApheresisApheresis

Platelets Pheresis

One bag (unit) One bag (unit) from one donorfrom one donor

One unit is a One unit is a therapeutic dosetherapeutic dose

Volume Volume approximately 250 approximately 250 ccsccs

GranulocytesGranulocytes

Lymphocyte Monocyte

Neutrophils Eosinophils Basophils

Granulocytes Primary use is for patients with neutropenia who

have gram negative infections documented by culture, but are unresponsive to antibiotics.

Therapeutic efficacy and indications for granulocyte transfusions are not well defined.

Better antimicrobial agents and use of granulocyte and macrophage colony stimulating factors best for adults, best success with this component has been with babies

Daily transfusions are necessary. Prepared by hemapheresis. Expiration time is 24 hours but best to infuse ASAP. Store at 20-24 C.

Plasma ComponentsPlasma Components

Fresh Frozen Plasma – Fresh Frozen Plasma – Volume 200-250ccVolume 200-250cc

Fresh Frozen Plasma (FFP)

Used to replace labile and non-labile coagulation factors in massively bleeding patients OR treat bleeding associated with clotting factor deficiencies when factor concentrate is not available.

Must be frozen within 8 hours of collection. Expiration

– frozen - 1 year stored at <-18 C.– frozen - 7 years stored at <-65 C.thawed - 24

hours

Fresh Frozen Plasma (FFP)

Storage temperature– frozen -18 C, preferably -30 C or lower– thawed - 1-6 C

Thawed in 30-37C water bath or FDA approved microwave

Must have mechanism to detect units which have thawed and refrozen due to improper storage.

Must be ABO compatible

Plasma, Liquid Plasma, Recovered Plasma and Source Plasma

Used to treat patients with stable clotting factor deficiencies for which no concentrate is available or for patients undergoing therapeutic plasmapheresis.

Prepared by separating the plasma from the RBCs on or before the 5th day after expiration of the whole blood.

Once separated can:– Freeze, store at -18 C for 5 years– If not frozen, called liquid plasma, store at 1-6 C for up

to 5 days after expiration of WB. Once FFP is one year old can redesignate as

Plasma, expiration is 5 years.

Pooled Plasma/Solvent Detergent Treated

Most recently licensed product. Prepared from pools of no more than 2500 units of

ABO specific plasma frozen to preserve labile coagulation factors.

Treated with chemicals to inactivate lipid-enveloped viruses.

Contains labile and non-labile coagulation factors but lacks largest Von Willebrand’s factor multimers.

Used same as FFP.Safety concerns– Decreases disease transmission for diseases tested for.– Doesn’t inactivate viruses with non-lipid envelopes: parvo

virus B19, hepatitis A, and unrecognized pathogens

Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Cold insoluble portion of plasma that precipitates when FFP is thawed at 1-6C.

Cryoprecipitate contains high levels of Factor VIII and Fibrinogen, used for treatment of hemophiliacs and Von Willebrands when concentrates are not available.

Used most commonly for patients with DIC or low fibrinogen levels.

A therapeutic dose for an adult is 6 to 10 units. Can be prepared from WB which is then designated as

"Whole Blood Cryoprecipitate Removed" or from FFP– Plasma is frozen.– Plasma is then thawed at 1-6 C, a precipitate forms.– Plasma is centrifuged, cryoprecipitate will go to

bottom.– Remove plasma, freeze within 1 hour of preparation

FFP

Frozen within 8 hours

Thawed FFP

Cryoprecipitate (VIII, vW)

Plasma cryoprecipitate, reduced (TTP, FII, V, Vii, IX, X, XI)

Thaw at 30-37°C Store at RT 4 hrs

Refrozen with 24 hrs of separation Store at ≤18°C 1 yr

5 day expiration at 1-6°C

Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Storage Temperature– Frozen -18 C or lower– Thawed - room temperature

Expiration:– Frozen 1 year– Thawed 6 hours– Pooled 4 hours

Best to be ABO compatible but not important due to small volume

Cryoprecipitate – volume Cryoprecipitate – volume 15ccs15ccs

Irradiation of Blood Components

Irradiation of Blood Components

Cellular blood components are irradiated to destroy viable T- lymphocytes which may cause Graft Versus Host Disease (GVHD).

GVHD is a disease that results when immunocompetent, viable lymphocytes in donor blood engraft in an immunocompromised host, recognize the patient tissues as foreign and produce antibodies against patient tissues, primarily skin, liver and GI tract. The resulting disease has serious consequences including death.

GVHD may be chronic or acute

Irradiation of Blood Components

Patients at greatest risk are:– severely immunosuppressed,– immunocompromised, – receive blood donated by relatives, or – fetuses receiving intrauterine transfusions

Irradiation inactivates lymphocytes, leaving platelets, RBCs and granulocytes relatively undamaged.

Must be labeled "irradiated". Expiration date of Red Blood Cell donor unit

changes to 28 days. May be transfused to "normal" patients if not used

by intended recipient.

Irradiation of Blood Components

Donor Blood Inspection and Disposition

It is required that donor units be inspected periodically during storage and prior to issuing to patient.

The following may indicate an unacceptable unit:– Red cell mass looks purple or clots are visible.– Zone of hemolysis observed just above RBC mass, look for

hemolysis in sprigs, especially those closest to the unit.– Plasma or supernatant plasma appears murky, purple,

brown or red.– A greenish hue need not cause a unit to be rejected.– Inspect platelets for aggregates.

Inspect FFP and CRYO for signs of thawing, evidence of cracks in bag, or unusual turbidity in CRYO or FFP (i.e., extreme lipemia).

Inspection of Donor BloodInspection of Donor Blood

Segment closest to Segment closest to unit is hemolyzed.unit is hemolyzed.

May indicate May indicate bacterial bacterial contaminationcontamination

Donor Blood Inspection and Disposition

If a unit's appearance looks questionable do the following:– Quarantine unit until disposition is decided.– Gently mix, allow to settle and observe appearance.

If bacterial contamination is suspected the unit should be cultured and a gram stain performed.

Positive blood cultures usually indicative of:– Inadequate donor arm preparation– Improper pooling technique– Health of donor - bacteremia in donor

If one component is contaminated, other components prepared from the same donor unit may be contaminated.

Inspection of Donor BloodInspection of Donor Blood Reissuing blood cannot be done unless the

following criteria is met:– Container closure must not have been penetrated or

entered in any manner.– Most facilities set 30" time limit for accepting units back,

warming above 6-10C even with subsequent cooling increases RBC metabolism producing hemolysis and permitting bacterial growth.

– Blood must have been kept at the appropriate temperature.

– One sealed segment must remain attached to container.– Records must indicate that blood has been reissued and

inspected prior to reissue.

Transportation of Blood and Blood Components

WB and RBC– Sturdy well insulated cardboard and/or

styrofoam container, wet ice in ziplock bag to cool, temperature must be monitored.

– Mobile collection units should transport blood ASAP and leave at RT if platelets are to be made.

– In-house transport place in cooler with wet ice and thermometer, monitor temperature every 30 minutes.

Safe-T-Vue Temperature Safe-T-Vue Temperature MonitorMonitor

Transportation of Blood and Blood Components

Frozen components– Temperature must be maintained at or below

required storage temperature.– Use dry ice in well insulated container.

Platelets and granulocytes– Maintain at 20-24 C.– Transport in well insulated containers without

ice. Commercial coolers available to maintain

at 20-24C.

Transportation of Blood and Blood Components

Handling donor units– Should not remain at RT unnecessarily,

when blood is issued it should be transfused as soon as possible.

– When numerous units are removed from fridge, remove fluid filled container with a thermometer at same time as blood, when temperature reaches 6 C return to fridge.

Records

Must be made concurrently with each step of component preparation, being as detailed as possible for clear understanding.

Must be legible and indelible. Must include dates of various steps

and person responsible.

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