COMPONENT

PRODUCTION

1
Components
 Describe how differential centrifugation is utilized to
prepare components such as platelet concentrate &
cryoprecipitate.
 Differentiate among the following components in terms of
preparation, storage temperature, shelf life, composition,
approximate volume, & quality control standards: whole
blood, packed RBC's, leukocyte reduced RBC's, frozen
RBC's, rejuvenated RBC's, fresh frozen plasma, single
donor plasma, cryoprecipitate, & platelet apheresis
products.
 Given a component, diagram the appropriate method for
its preparation from a freshly drawn unit of whole blood.

2
Milestones in the Development of
Transfusion Practice
 1665First transfusion (dog to dog)
 1667 Dennis
 first human transfusion (lamb’s blood)
 1818 Blundell
 first human transfusion with human blood
 1900 Landsteiner
 discovered ABO blood groups
 1907 Ottenberg
 introduced pretransfusion compatibility testing

3
Post World War II:

 Expansion of Blood
Bank network
 Use of plastic tubing
& bags for storage

4
Post World War II:

 Development of
blood component
therapy
 Testing of blood for
infectious agents

5
Plastic Bag

“The surgeon who developed

the plastic bag, Carl W.
Walter, MD, was also a
brilliant chemist and inventor.
In 1932, as a surgical
resident at the Peter Bent
Brigham Hospital in Boston,
he had a messy accident with
a broken, blood-filled
Kimpton-Brown glass
transfusion apparatus in the
operating room.”
6
Plastic Bag

“During the ensuing chaos, the surgeon-in-chief

reprimanded him for swearing and challenged
him to find a better approach. Walter eventually
came to the realization that lightweight,
malleable plastic could provide a container with
physiologic pressures, a nonclotting surface,
sterility, and sufficient sturdiness for
centrifugation.”

7
Plastic Bag
“Over Thanksgiving vacation in 1947, he
fashioned a primitive bag with diaphragm-sealed
tube and ports. And on the following Monday, he
drew up a patent claim. Commercial concerns
were at first unimpressed, and Walter instead
gathered his own experts to work on needed
improvements to the plastic.”

8
Plastic Bag
“His company became Fenwal, Incorporated (the
name was an amalgamation of his own and his
next-door neighbor’s, an investment counselor
named T. Legare Fenn, who helped with the
financing). Some of the initial clinical trials of the
polyvinyl resin blood bag, fittingly enough, took
place at the Brigham.”

Transfusion, Volume 40, July 2000

9
Blood Volume
 45% of blood volume is cellular
 Red cells, white cells, platelets
 55% of blood volume is liquid
 plasma

 Average adult has approximately five liters of

blood
 10 to 12 pints or 70 mL/kg of body weight
 7 to 10% of a person’s weight is blood
AABB Primer of Blood Administration; 2004.

10
11
Component Therapy

12
Advantages of
Component Therapy

 Patient receives only component

needed
 More than one patient can be treated
with each blood donation
 Each component can be stored under
optimal conditions
13
Reasons for Transfusion
 Replace oxygen carrying capacity
 Replace coagulation factors
 Fight infections

14
15
16
 Whole Blood

 HCT of unit of WB:

36 to 44%
 Few viable platelets or
granulocytes after 24 hrs
 Levels of Factor V and
VIII decrease

17
WHOLE BLOOD
 Volume: 450 ml +- 10%
 Anticoagulant: 63 ml
 Expiration: 21 to 35 days
 Storage Temp: 1 to 6 C
 HCT increase: 3% in adult

 Administer through filter

 Infuse within 4 hours

18
Indications for WB
 Provides oxygen carrying capacity, stable
coagulation factors and blood volume
 Actively bleeding
 Loss of > 25% blood volume
 For massive blood loss, transfuse as fast as
patient can tolerate
 Usually transfused over 1 ½ to 4 hours

19
Whole Blood

 Must be ABO Identical

 Must be crossmatched
 Risk of circulatory overload is greater in
certain patients
 Most WB is processed into components

20
Whole Blood Must Be ABO
Identical

Recipient’s Donor’s
Blood Group Blood Group
A A

B B

AB AB

O O
21
Whole Blood Characteristics
After Storage in CPDA-1
 Plasma dextrose
 Plasma K
 pH
 Lactate
 Plasma LDH
 Whole-blood ammonia
 Plasma hemoglobin
 2,3 DPG
 ATP

22
PACKED RED
BLOOD CELLS
LEUKOCYTE REDUCED BY
FILTRATION

23
Blood Products: PRBCs
Single Donor (1 unit= ~300cc) or Pheresis (2 units)
• Typical HCT 0.65-0.7
• Need to anticoagulate
• Citrate-phosphate-dextrose-adenine (CPDA)
• Extended storage, additive solutions (AS), Plasma
removed first
 Adsol (AS-1)
 Nutricel (AS-3)
 Optisol (AS-5)

24
 PACKED RED BLOOD
CELLS
 Shelf life: 21-42 days
 Storage Temp: 1- 6 C
 Restore or maintain
O2-carrying capacity for
symptomatic patients who
are not treatable within a
reasonable amount of time
with iron, vitamin B12, folic
acid or erythropoietin
 Demand for O2 varies
 HCT increase
25
Blood Components
• Red Cells – CPDA-1
– prepared by removing ~ 80%
of plasma in Whole Blood -
avg. vol. ~ 250 to 300 mL
– hct cannot be greater than
80%
– by removing plasma - vol. is
reduced & still get the same
O2 carrying capacity
– 35 day expiration

26
  Red Cells with
Adenine-saline-
preservative
 remove an additional 50
mL of plasma that is
replaced with 150 ml
adenine-saline
 increases shelf life of cells
to 42 days
AS1  Hematocrit of final product
is 55-65%
27
 Red Cells Aliquots
 most often transfused to
neonates 2nd to
 fetomaternal bleed

 hemorrhage

 iatrogenic anemia [lab

tests]
vol.is usually 10 to 25 mL
Sterile docking - life of unit
enter unit then 24 hours

28
 Red Cells Irradiated
 reduce risk of graft versus
host disease in
 allogeneic bone

marrow transplants &

 fetal transfusions

 immunodeficiencies

 Hodgkins

 max. shelf life is 28 days

or the shelf life of the
original unit, whichever
occurs 1st
29
 Leuko-reduced Red Cells
 absolute WBC count is <5 x 106
 at least 85% of original RBC mass
is retained
 95% of units tested have less WBC
 used for
 febrile reactions 2nd to ab’s to

WBC’s
 is not used for graft vs. host

 avoid transfusion transmitted CMV

 avoid sensitization to WBC Ag’s

30
LEUKOCYTE REDUCED
RED BLOOD CELLS
 WBC < 5 x 10 6
 Repeated febrile
transfusion reactions
 Prophylaxis against
alloimmunization
 Prevention of CMV
transmission

31
LEUKOCYTE REDUCED
RED BLOOD CELLS
 Expiration: Depends
on anticoagulant
 Storage Temp:
1 to 6 C
 Transfuse in < 4
hours

32
Packed Red Blood Cells
 Volume: ~ ½ of WB
 Transfused as fast as patient can tolerate
but < 4 hours (1 ½ to 4 usual)
 Must crossmatch
 Very little plasma - does not have to be
group specific
 Must be ABO compatible
O universal donor
AB universal recipient

33
Choice of Packed Cells

Recipient’s Donor’s
Blood Group Blood Group
A A, O

B B, O

AB AB, A, B, O

O O
34
PACKED RED BLOOD CELLS
Indications for:
 Measurement of HCT/Hgb only cannot
accurately assess the need for
transfusion
 Hemoglobin: 6 – 10 g/dL
 Tachycardia
 Hypotension

 Mixed venous pO2 <25 torr

35
 Packed Red Blood Cells
 Symptoms of anemia
 Generalized
weakness
 Headache
 Dizziness
 Disorientation
 Breathlessness
 Palpitations or chest
pain
 Tachycardia
36
WASHED RED BLOOD CELLS
 To remove plasma
 Suspend in normal saline
 Removes 98% plasma
 Reduces concentration of leukocytes
 Removes platelets and cellular debris

 Prevent recurrent or severe allergic reactions,

IgA deficient patients
 Expiration changes to 24 hours
 Storage Temp: 1 to 6 C

37
Frozen Red blood
cells

38
Deglycerolization

High Glycerol Low Glycerol

 Slow uncontrolled  Rapid, more
freezing at –65 C controlled freezing
or lower  -120 C or lower
 Larger volume of  Temperature
wash solutions to fluctuations can
remove damage rbcs
 Most common

39
 Frozen Red Blood Cells -
Deglycerolized
 Expiration:
 10 years (while frozen)
store at -65C or colder
 24 hours “after
thawing” stored at 1-
6C
 Approximately 1 hour to
thaw and “deglycerolize”

40
Frozen PRBC
• 10% glycerol long term storage frozen
• Thaw and wash away glycerol
• WBC and CMV destroyed by this.
• For rare blood types or multiple
alloantibodies

41
Deglyerolization
 Quality Control
 Recovery of 80% rbcs
 Sickle cell positive
 70% viability after 24
units will not
survive routine
hours
freezing and
 <1% residual glycerol
deglycerolization
 Osmolarity

 Simulate

transfusion

42
PLATELETS

43
 Preparation of Platelets
 Whole Blood

 Short light spin

 2-3 minutes/3200RPMs

44
 Preparation of Platelets
Separate into:
Packed red cells
Platelet rich plasma
Heavy spin – 5min/3600 RPMs
Following spin: “Rest” 1 to 2 hrs

Packed cell Plt rich plasma Packed cell plasma

45
Plt concentrate
 Platelet Concentrate
 must be produced within 4 hrs.
of unit’s collection
 is prepared at same time as
packed red cells are prepared
 random donor platelet unit
must contain at least 5.5 x 1010
platelets and pH of 6.2 or
higher
 stored at 20 to 24C with
continuous agitation
 contain 50 to 70 mL’s of
plasma
 shelf life is 5 days

46
 concentrate from a single unit
is referred to as random-
donor platelets
 when harvested by
plasmapheresis, called single
donor platelets

47
Pheresis
 Apheresis (or just pheresis):
Greek: apo+hairien to take away

48
 Pheresed single donor
platelets
 contain at least 3.0 x 1011
platelets
 have about 300 mLs
 Reduces exposure to
donors

49
Collection & Storage
Whole blood derived Apheresis

Platelet count 7 x 1010 4 x 1011

Volume 50 ml 300 ml
Concentration 1.5 x 109/ml 1.5 x 109/ml
Leukocyte count Higher Lower
Red cell count Same Same

Risk of FNHTR Higher

Risk of ABO related Higher
hemolysis

50
PLATELETS

 Platelet concentrates
 Whole Blood Donation
5.5 x 10 10 platelets
50 – 70 ml plasma to
maintain pH of 6.2 or >
 Platelet pheresis
 Apheresis collection
3 x 10 11 platelets

51
Functionally Abnormal Platelets
 Exposure of blood to the extra corporeal
circuit (ECMO) leads to impairment of the
hemostatic system and a predisposition to
excessive bleeding
 Hypothermia (<95C)

52
Platelets
Indications:
 Platelet count
 <20,000/uL
 <50,000/uL– scheduled for minor procedure
 <100,000/uL – scheduled for major surgery

 Probably do not need to transfuse unless below

10,000/uL if platelets are functioning normally

53
PLATELETS - CONTRAINDICATIONS

 Patients with rapid platelet destruction (may

not be effective – use only in presence of
active bleeding and with careful monitoring)
 Idiopathicautoimmune thrombocytopenic
purpura (ITP)
 Untreated disseminated intravascular
coagulation (DIC)
 Relatively contraindicated in:
 Thrombotic thrombocytopenic purpura (TTP)
 Heparin-induced thrombocytopenia (HIT)
54
Platelets - Dosage
 1 unit (WB Donation)
 5,000/uL increase
 1 platelet pheresis (4 to 8 donors)
 20,000 to 40,000/uL increase
 Platelet refractoriness
 Poor increment following a dose
 Either immune or nonimmune mechanism

55
Platelet Refractoriness
 Immune
 HLA or platelet alloantibodies

 Nonimmune
 Bleeding
 Splenomegaly
 DIC
 Fever
 Sepsis

56
ABO Group Considerations for
Platelet Transfusions
 Rh matters - Some rbc contamination
 If Rh neg female gets Rh Pos - RHIG
 Crossmatch if > 2 ml of rbcs
 Plasma should be compatible
 ABO-incompatible
 Pos DAT
 Rarely hemolysis

 Leukoreduced
 May be washed
57
Platelet Preparation for
Transfusion
 A dose of random donor (WB) platelets is
usually 4-6 platelets that are pooled into a
single bag
 Expiration is 4 hours at RT
 A platelet pheresis may consist of one
single bag or two joined bags.
 If
2 bags, pool together prior to transfusion
 Expiration after pooling is 24 hours at RT

58
CRYOPRECIPITATE

59
Cryoprecipitate Preparation

 FFP is frozen
 Thawed slowly at 1-6 C
 Cold insoluble portion
removed
 Storage: -18 C or lower
 Expiration: 12 months

60
 Cryoprecipitate
 predominately
 factor VIII at least 80 (to
120) units of activity &
 fibrinogen 150 to 250 mg

 factor XIII &

 von Willebrand’s

 prepared by freezing
plasma within ~ 4 to 6 hrs.
of collecting unit.
 plasma is then thawed
slowly at 1 to 6C

61
 remove all but about 10 to 15
mL’s of plasma
 precipitate can then be frozen
up to 12 months

62
CRYOPRECIPITATE contains:
 Factor VIII:C 80 to 120 units
 Factor VIII:vWF
 Fibrinogen
 Onlyconcentrated product currently available
 Contains approximately 250 mg (150mg)

 Factor XIII
 Fibronectin

63
Preparation of Cryo for Transfusion

 Before infusion - Thaw at 30-37 C.

 Stored at RT (20 –24 C) after
preparation
 Expiration
 Singleunit –6 hours
 Pooled - 4 hours
 Compatibility: follow chart for FFP
 Very little volume
64
CRYOPRECIPITATE
 Transfused over less than 4 hours
 Usually 15 to 30 minutes
 Indications for use:
 Fibrinogen replacement
 Topically as a fibrin sealant
 Severe vonWillebrand disease only if not responsive to
DDAVP
 Seldom used to replace Factor VIII in Hemophilia A –
use virally inactivated or recombinant Factor VIII or
DDAVP

65
GRANULOCYTE
CONCENTRATES

66
Granulocytes (Leukapheresis)
 Indications
 Neutropenia
 Unresponsiveto antibiotics
 Reasonable chance for recovery of marrow
function

67
Preparation
 Cytapheresis of single donor (most
common method)
 “Buffy coat” prep from single units of fresh
WB for neonates

68
Granulocytes
 24 hour expiration
 Stored at Room Temperature (20 to 24 C)
 Red cell compatibility (crossmatch) must be
performed
 Minimum transfusion of 1-2 x 10 10 granulocytes
given in four daily doses have been reported to
demonstrate clinical benefit
 Blood administration set with 150-280 micron filter
 Do not use leukocyte reduction filters

69
 Granulocyte
Concentrates
 collectedby
cytopheresis
 should contain 1 x 1010
granulocytes
 if steroid have been given
to donor 12 to 24 hrs.
before collection OR
 hydroxyethyl starch
[HES] is used to enhance
separation
 should
contain 200 to
600 mL of plasma
70
 store at 20 to 24C &
 use within 24 hrs [as soon
as possible]
 mainly used for
neonatal sepsis
 have had most success
with severe neutropenias,
fevers unresponsive to
antibiotics for 24 to 48
hrs. & myeloid hypoplasia

71
PLASMA

72
 Single Donor Plasma  Fresh Frozen
a by product of WB,
platelet concentrate,
or cryoprecipitate
 used as a source of
stable clotting factors
only & 2ndarily vol.
expander
 most used in prep of
plasma protein
fraction, serum
albumin, & immune
globulin
Plasma
 Frozen within 8 hrs.
of collection at –18C
or lower.
 Has both stabile &
labile factors
 Used when there is
active bleeding,
multiple clotting
factor deficiencies
73
Preparation of Plasma
Whole Blood

74
 FRESH FROZEN PLASMA

 Volume approximately
250 ml
 Expiration
1 year if frozen (-18C or
lower)
 24 hours thawed (1 to 6
C)

75
FRESH FROZEN PLASMA
 Expected Increase in 70kg adult
1 Unit increases most factors approx. 2.5%
 4 Units increase most factors approx. 10%
 Indications for use:
 Clinically significant deficiencies of Factors II, V, X
and XI.
 Multiple factor deficiencies
 Liver disease
 Warfarin treatment (Vitamin K antagonist)
 Dilutional and consumption coagulopathy
 Plasma exchange treatment for TTP or HUS
 Replace deficient vWF processing protease in TTP
76
Transfusion of FFP
Recipient’s Donor’s
Blood Group Blood Group
A A, AB

B B, AB

AB AB

O O, A, B, AB

77
Note: Rh need not be considered for FFP
FFP Notes

 Thaw at 30-38 C
 Water bath –over wrap
 Microwaves
 Expiration :24 hours after
thawing to be called FFP
 Does not need to be
crossmatched
 Transfusion time usually
30 to 60 minutes

78
 FFP Notes
 Recovered Plasma
Up to 5 days after unit
expiration
 Solvent/detergent-
treated plasma
 Treated with a solvent
and a detergent to
eliminate lipid-enveloped
viruses
 Used in Europe but
phased out in the U.S.
79
 Factor VIII concentrate
 For classic hemophilia A bleeding disorders
and at times for von Willebrand’s
 Usually from large volumes of pooled
plasma which has high risk for transmission
of viral diseases. To avoid
 Pasteurization

 Stabilizers: albumin, sucrose or

glycerine prevent denaturation of
Factor VIII during heating for 10 hrs. at
60C
 Protects against hepatitis & HIV but
loose large amts. of Factor VIII
80
 Solvent & Detergent
 Used to disrupt the viral coat

 The solvent are then removed & concentrate

is lypholized
 Very little loss of Factor VIII [~10%]

 Monoclonal Purification

 Use immunoaffinity with monoclonal antibody

against Factor VIII & von Willebrand’s
 The factors are bound to the antibody and
trapped in the solid substrate.
 Permits concentration of large amounts of
both factors with no evidence of disease
transmission to date

81
  Porcine Factor VIII
 Used when hemophiliac has developed inhibitors
 Purification techniques have improved & reduced
side effects
 Factor IX Concentrate
 Frompooled plasma
 Newer product is purified by immunoaffinity
 Contains more Factor IX, less II, VII & X
 Fewer problems with formation of thrombi

 Used primarily for Factor IX deficiency

[hemophilia B or Christmas disease]

82
Blood Components Review
W h o le B lo od U n it
ce n trifu ge

R e d B loo d C e lls P la te le t-R ich W h ite B lo o d C e lls

P la sm a
ce n trifu ge fre e ze fre e ze-th aw
P la te le ts F re sh F ro zen C ryo p recip ita ted
P la sm a AHF

83
 Requirements for
Storage and Expiration
Component Storage Transport Expiration

RBCs or 1-6C 1-10C ACD/CPD/CP2D: 21

RBCs leuko- days
reduced Additive solutions:42
days
Open system: 24
hours
RBCs- 1-6C 1-10C 24 hours
deglycerolize
d or washed
84
 Requirements for
Storage and Expiration
Component Storage Transport Expiration

RBCs frozen Keep in 10 years

40% ≤ -65C frozen state Develop policy if
20% ≤ -120C held longer
Platelets 20-24C 20-24C 5 days
with Max. time without
agitation agitation: 24 hours
Granulocyte 20-24C 20-24 C 24 hours

85
 Requirements for
Storage and Expiration
Component Storage Transport Expiration

Cryoprecip- ≤-18C Keep frozen 12 months

itated AHF
Cryo-thawed 20-24C 20-24C Open/pooled: 4 hrs
Single unit: 6 hrs
FFP ≤ -18C Keep frozen ≤ -18C: 12 months
≤ -65C ≤ - 65C: 7 years
FFP thawed 1-6C 1-10C 24 hours

86
 Component Storage
Component temp Expiration transfusion

Whole Blood 1-6C 35 or 42 Xm

days
PRBC – 1-6C Same as Xm
Leukocyte above
reduced
Platelets 20-24C 5 days 4 hours
FFP <-18C 1 year 24 hours
6 hours, 4 hours
Cryo <-18C 1 year pooled

Pheresis Platelets 20-24C 5 days

87
CPDA-1
CPDA-1 AS1 CPDA-1
Fresh RBC 42 days 35 days
RBC
Viable cells 100% 76% 71%
pH 7.55 6.6 6.71
ATP 100% 60% 45%
2,3DPG 100% <5% <10%
K+ mmol/L 5.10 50 78.5
Plasma Hgb mg/L 78 n/a 658 88
Multiple Components Needed

Transfusion Therapy

89
Blood longevity
 RBC 120 days
 WBC 7 hrs
 Platelets 10 days

90
With Age of Stored RBC
 K+ rises accelerated by irradiation
 Free Hb rises
 2,3 DPG falls (O2 dissociation curve shifts
to left, increasing affinity)
 Intracellular Ph falls

91
PRBC: Storage Solutions

CPDA-1 AS-1 AS-3 AS-5

Volume (ml) 63 100 100 100

NaCl (mg) --- 900 410 877
Dextrose (mg) 2000 2200 1100 900
Adenine (mg) 17.3 27 30 30
Mannitol (mg) --- 750 --- 525
Trisodium citrate (mg) 1660 --- 588 ---
Citric acid (mg) 206 --- 42 ---
Sodium 140 --- 276 ---
Phosphate (mg)

92
PRBC Options
• Leukoreduction:
 Reduces leukocytes to ‹ 5x106 per unit-
 Filtration

 Alloimmunization to histocompatibility Ags

 Viral transmission, including CMV

 Febrile reactions

 TA-GVHD

• Radiation:
• 25Gy, inactivate T cells. Applies only to fresh
components (PRBC, plt, grans)
• Immunocompromised: BMT, onc, heart, lung
transplant
93
 CMV
• Lives in WBC
• Leukoreduced blood as safe as
seronegative blood
• Indication CMV negative blood
• All premies, sick neonates
• Immunodeficient patients
• Oncology
• Transplant recipients

94
PRBC Options, cont’d
• Washing: PRBC
• IgA deficient
• Persistent allergic reaction
• Removes proteins
• Use 1-2l Normal saline
• 20% RBC lost
• Use within 24hrs
• Washing: Platelets
• Use NS or buffered saline
• Retains 90% platelets
• Must be used within 4hrs
• Sickle negative
• Standard for all sickle cell patients
• Standard for ECMO, exchange 95
 Transfusion Associated Graft
Versus Host Disease
• 90% fatality
• Immunodeficient host
• Interuterine transfusion. Exchange, ECMO
• Oncology Pt
• BMT
• HLA heterozygous who receives transfusion form HLA
homozygous relative- always irradiate relative’s blood

96
Irradiation
• 2500Gy
• Kills all dividing cells (T-cells)
• Increases K+ in stored RBC
• Shortens storage life to 28days

97
Platelets

98
Blood Products: Platelet

 Dosed in equivalent units (~50cc/unit)

~6 equivalent units per pheresis platelet product
 1 unit/10kg raises plt count 50,000
 Matching
 ABO ideal, but not necessary (weakly expressed)
 Ex: 20kg non-bleeding child, plt count 7,000: 2
units

99
Platelet Options
 Leukoreduced (Universal)
 Concentrated
 Allergic reaction
 Volume reduction (must be severe restriction)
 Washed
 Moderate/persistent or Severe allergic reaction
 IgA deficient
 Note: Reduced plt number and function with
concentration/washing
 Irradiated

100
Platelet Options
 Platelet Concentration
 From whole blood donation –random donor platelets –RDP 5-7
E10 plt 50-60ml
 0.1u/kg increases platelets by 50,000
 Apheresis single donor platelets SDP, 3-5E11, =5-8U of RDP or
150-400ml
 Other information
 Infection risk rises after day 5
 ABO and RH specific (not always done)

101
Blood Products: Platelet
 CCI Plt increment x BSA
 1h >5000 # units transfused
 24h >2500
Ex: 7,000-37,000 1h after 2 units:
30,000* 0.6m2 = 15,000
2
 If bad increment
 Consumption (fever, splenomegaly, DIC, infection)
 HLA alloimunized: match HLA-A, HLA-B loci (check with
Quick Screen (screen for anti-HLA Ab)
 Rarely HPA alloimmunized
 Amphoteracin other antibiotics
 IVIG if in a bind
102
Treatment of Platelet
Refractoriness
 HLA antibodies
 HLA matched
 X-matched compatible platelets
 Platelet allo-antibodies
 Antigen match
 X-matched compatible platelets
 Auto antibodies
 IVIG
 Steroids
 Splenectomy

103
Blood Products: FFP
Fresh frozen plasma (unit= ~300cc)
 Prepared from plasma separated from whole blood
 Frozen within 8 hours= FFP
 Most “24h plasma”
 Used for factor replacement
 10cc/kg gives 20% factor activity
 Except I, VIII, XIII (use cryo)
 1 Unit ~300cc

NO OPTIONS
(Don’t ask for washed plasma)

104
Blood Products: Cryoprecipitate

• Prepared from thawed frozen plasma

• Used for factor replacement
• I, VIII, vWF, XIII
• Given with plt transfusion for qualitative defects
(uremia)
• 1 unit per 10 kg (adult= “10-pack”)
• Unit = 10-15cc

-O- 105
Granulocytes
 Indications
 ANC <500 or qualitative defect
 Documented bacterial/fungal infection not
responsive to Abx
 Chance for neutrophil recovery
 < 2weeks old, bacterial sepsis, neutrophils <300
 Must be ABO/Rh compatible
 Irradiated
 Used ASAP <4h (some 6-10hr)
 Donors get dex or G-CSF
 Study to open at JHH
106
Transfusion and Transplant
 Stem cells don’t express A,B
 Can transplant across ABO
 Minor (incompatible plasma for the recipient)
 Donor has anti-A or anti-B in plasma
 O donor into A recipient
 Passenger lymphocyte
 Major (incompatible cells for the recipient)
 Recipient makes anti-A or anti-B
 A donor into O recipient
 Bonus: B into A?
 Minor: donor has anti-A
 Major: recipient makes anti-B
107
Acquired Bleeding Disorders

 Liver Disease
 Disseminated Intravascular Coagulation
 Sepsis,
trauma, OB complications,
malignancy, intravascular hemolysis

108
Vitamin K Deficiency and
Antagonism
 Fat soluble vitamin necessary for synthesis in liver of
Factors II, VII, IX, X, protein C and protein S
 Deficiency can occur in patients in intensive care
unit, those with chronic disease and receiving
antibiotics and those with general fat malabsorption
states such as celiac disease or obstructive jaundice
 Oral Anticoagulants (warfarin) interfere with Vitamin-
K dependent synthesis of Factors

109
Liver Disease
 Coagulation factors are synthesized in the
liver
 May have multiple coag problems
 Coagulation factor deficiency
 Impaired vitamin K utilization

110
Disseminated Intravascular
Coagulation (DIC)
 Uncontrolled activation of coagulation and
secondary fibrinolysis
 Thrombin is generated by pathologic
release of tissue factor into the blood or by
widespread endothelial damage

111
Disseminated Intravascular
Coagulation (DIC)
 Treat underlying cause
 Chief clinical manifestation
 Bleeding due to consumption of platelets and
coag factors (fibrinogen)
 Common clinical conditions predisposed
 Sepsis, trauma, OB complications,
intravascular hemolysis, malignancy

112
PLASMA DERIVATIVES
 Factor VIII (concentrates/recombinant)
 Factor IX (concentrates/recombinant)
 Immune Globulin
 Antithrombin
 Activated Protein C (recombinant)
 Factor VIIa (recombinant)

113
Hemophilia A
 X- linked congenital bleeding disorder
 Gene deletion or point mutation
 Factor VIII deficiency (Coagulant portion)
 Hemophilic bleeding manifests several hours after
the trauma and occurs most frequently in deep
structures (joints, muscles)
 Von Willebrand Factor Levels are normal
 Mild or moderate hemophilia A can be treated with
DDAVP
 Severe disease usually requires infusion of Factor
VIII concentrates
 10-15% develop antibodies after repeated infusions
114
Hemophilia B
 Clinically manifests like Hemophilia A
 Factor IX Deficiency
 Treated with Factor IX concentrates
 DDAVP is not effective

115
Factor VIII concentrate
 Human plasma or recombinant technology
 Recombinant produced in established hamster
cell lines
 stabilized with the addition of human albumin
 Recombinant product of choice

 Sterile, stable, lyophilized concentrate

 Viral inactivation
 Combination of pasteurization and
solvent/detergent treatment
 Affinity chromatography
116
Factor VIII Indications

 Treatment or prevention
of bleeding episodes in
hemophilia A
 Certain Factor VIII
concentrates have been
used to treat vWD
 Humate-P
 Alphanate
 Koate DVI

117
Dose and Administration
 Quantity of Factor VIII coagulant activity is stated
on the bottle in IU
 Reconstitute with sterile diluent
 1 IU is amount Factor VIII present in 1 ml of normal
plasma
 Formula:
Desired units of Factor VIII =
Plasma Volume x {Desired level (%) – initial level (%)}
100

118
Factor IX Concentrate
 Plasma derived
 Highly purified preparation with trace amounts
of Factors II, VII, X
 Recombinant (Chinese hamster ovary cell
line)
 Treatment of choice for hemophilia B

119
Antithrombin Concentrate
 Inhibitor of thrombin, activated Factors
IX,X,XI,XII
 Used to treat patients with hereditary AT
deficiency who have thrombosis or require
prophylaxis when scheduled for surgery
 Pooled human plasma - heat treated

120
Factor VIIa

 Recently licensed to
treat bleeding in
hemophilia patients with
inhibitor
 Probably works by
enhancing thrombin
generation through
direct activation of
Factor X leading to
thrombin activated
platelet surfaces
121
Factor VIIa

 Also used in other

clinical situations
(not licensed)
 Trauma patients
 Liver disease
 Glanzmann’s
thrombasthenia

122
 Factor VIIa (NovoSeven)
 Binds with tissue factor to
activate factor X.
 Binds directly to activated
platelets (no effect on
unactivated) promoting the
generation of factor Xa on
the platelet surface to
produce thrombin
 Thrombin generated on
the platelet surface
promotes formation of a
stable fibrin clot
123
Protein C Concentrate

 Inhibitor of coagulation
 Vitamin K dependent
 Inhibits activated Factors V and VIII in
presence of Protein S
 Treatment of Protein C Deficiency

124
Fibrin Sealant
 FDA has licensed a fibrin sealant kit
 Uses lyophilized, virus inactivated pooled
human fibrinogen and thrombin with a bovine
albumin stabilizer
 Applied to surgical site to generate a cross
linked fibrin clot to stem bleeding

125
Immune Globulin
 Cold ethanol fractionation
 Pools of human plasma
 Gamma globulin preparation
 Provide passive antibody prophylaxis
 HBIG
 IVIG
 ITP

126
RHIG

 IgG anti-D
 IV or IM preparations
 Rh negative
individuals
 Within 72 hours
 300 ug dose
 15 ml rbcs
 30 ml WB

127
 History

 Drs. John Gorman and

Vincent Freda
developed Rhogam, the

  vaccine that allows

women with Rh-
                                   

negative blood to
deliver healthy Rh-
positive babies. Dr.
Freda also introduced
amniocentesis.

128
 RHIG

 ITP
 FDA approved for
Rh positive, non-
splenectomized
 IV administration
 Advantages of IV-Ig
 Lower cost

 Lower volume

129
Urgent and Massive
Transfusions
 Urgent Transfusion
 Administration of blood before pretransfusion
testing is complete
 Patient’s physician must sign stating nature of
emergency

130
Urgent and Massive
Transfusions
 Massive Transfusion
 Replacement of one or more blood volumes
within 24 hours (10 or > units)
 Four stages in massive transfusion setting
 Blood coagulation support
 Potential for fibrinolysis

 Hypothermia and platelet dysfunction

 Metabolic complications

131
Why do surgical patients bleed?
 Anatomic defects
 Dilution or consumption of coagulation
factors and platelets
 Hypothermia
 Below 33 C the clotting becomes slower
 Significant decrease in platelet adhesion as
temperature decreases
 Acidosis
 As pH decreases there is a decrease in
coag Factor activity
132
 Historical Reasons to Limit
Transfusions
 Risk of transfusion reaction
 Disease transmission
 Immunosuppression

133
Immunologic Effects
 T-cell proliferation, Natural killer cell
activity, and CD3, CD4 and CD8 T cells
are decreased
 Soluble cytokine receptors, serum
neopterin, cell-mediated lympholysis,
tumor necrosis factor alpha and
suppressor T-cell activity are increased

134
 Transfusion Immunomodulation
(TRIM)
 Rejection rates lower in transfused transplant patients
 Survival rates lower and recurrence rate higher in
transfused cancer patients
 Makino et al J Gastroenterology. 2000;95:1294-1300
 Landers et al Anesth Anlg. 1996;83:197-204
 Allogeneic transfusion
 Decreased cell mediated immunity
 Decreased macrophage migration
 Decreased NK cell activity
All of above reduced with LR products

135
 Transfusion is only blood replacement
therapy for acute blood loss
 However, 85% of transfusions in non-
trauma settings

136
 Current Reasons to Limit
Transfusions
 Documented increased morbidity and mortality
directly related to transfusion
 In trauma patients, transfusions are shown to be
independent markers of death, infection
Taylor et al CCM. 2002; 30:2249-2254
 Transfused trauma patients (after stratification for age,
etc.) suffer:
 10 fold increased risk for mortality and a 6 fold increase
in mean ICU LOS
Malone et al J Trauma. 2003; 54:898-907

137
Current Reasons to Limit Transfusions

 Study of 740 patients who had undergone

elective colorectal surgery
 Those receiving a transfusion were likely to
survive 3.0 years
 Those not receiving a transfusion lived 4.6
years

138
Current Reasons to Limit Transfusions

 Study of 687 geriatric patients undergoing

hip fracture surgery
 27% transfused developed postoperative
infections
 15% nontransfused did

139
Current Reasons to Limit Transfusions
 Correlation between transfusion doses and rates
of infection and mortality
 One study
 Patients receiving up to two transfusion had an
infection incidence of 0.2 or less
 Patients receiving 15 transfusions had incidence of
1.0
 Another study
 Infection odds ratio of 1.06 for patients receiving only
intraoperative transfusions and 9.28 for those
receiving more than 4 units
 Mortality odds ratio was 1.08 and 2.84 respectively
140
 Current Reasons to Limit
Transfusions
 Critically ill patients can tolerate a low
hemoglobin
 Restrictive transfusion strategies (7-9
gm/dl) and transfusion of 2.5 +- 3.8 units
carried about an 81% survival rate after 30
days, declining to 77% after 60
 Similar results with liberal transfusion
strategies (10-12 gm/dl)
 However, trend reversed with critically ill
patients with cardiovascular disease –
more liberally transfused fared better.
141
 Current Reasons to Limit
Transfusions
 Shortage of blood
 Aging donors
 Increasing exclusions

142
Transfusion Considerations
Corwin et al Chest 1995; 108-767
 85% patients in ICU >1 week received PCs
Most receive 9.5 units
Average 2-3 u/week
Anemia not due to acute blood loss
Multifactorial anemia of critical illness
 Chart review
Up to 40% transfused with no indication
 Transfusion triggers arbitrary
Rarely based on physiologic parameters

143
Irradiation - Review
 Indicated for cellular components that
contain viable lymphocytes for
immunosuppressed patients
 Prevent proliferation of transfused T lymphs
 Primary cause of TA-GVHD
 Donor units from relatives
 HLA matched platelets

144
Irradiation
 Dosage: 2500cGY to center of bag
 Lymphocytes: inhibits mitotic activity and blast
formation
 Granulocytes: No significant damage unless
extremely high dose
 Mature rbc: Extremely resistant; some K loss
 Platelet functions: Impaired function only at
very high levels

145
Confirming Irradiation
 Radio chromic film labels affixed to bags
prior to irradiation
 When exposed to an adequate amount the
film portion darkens indicating adequate
irradiation

146
Expiration Date –
Irradiated Products
 Red cell components – 28 days or original
expiration date of the unit whichever is
less
 Platelets – minimal damage – expiration
does not change

147
Indications for
Irradiated Products
 Patients at risk for TA-GVHD
 Fetuses receiving intrauterine transfusions
 Immunocompromised recipients
 Recipients undergoing marrow or progenitor
cell transplantation
 Recipients of HLA matched platelets
 Recipients of Donor units from blood relatives

148
Cytotoxic Drug Treatment
 Requirement for blood transfusion support
has increased dramatically with
 The design of new cytotoxic drug treatment
protocols
 More extensive use of these forms of
treatment for various malignant tumors

149
Cytotoxic Drug Treatment
 Cytotoxic drugs
 Act by either inhibiting cell division or by inhibiting
general cellular metabolism
 Are used in various combinations to treat different
cancers
 Malignancies
 Characterized by a large number of cells that are
actively dividing or in active metabolic states
 Other tissues in the body also consist of dividing and
metabolically active cells (bone marrow)

150
Roles in Blood Transfusion
 Blood Bank  Blood Administration
 Identify patient and  Prepare patient
sample  Prepare site and
 Perform all testing equipment
 Store and handle  Identify product
blood appropriately and patient
 Release correct  Administer product
product  Assess for
 Document reactions
 Document
151
Immediately before initiating
transfusion:
 Obtain vital signs
 Temperature, pulse, respirations, blood pressure
 Provide a baseline measurement against which any
changes during the transfusion can be compared
 Should be recorded in the patient record
 Fever:
 May be cause for delaying transfusion
 Could mask a symptom of an acute transfusion reaction
 May compromise the efficacy of platelet transfusions

152
Premedication
 May be required if patient has a history of adverse
reactions
 Patient’s mediation regimen should be reviewed prior
to transfusion
 Febrile reactions may be prevented by administering
acetaminophen
 Antihistamines my be required for patients with a
history of allergic reactions
 Meperidine hydrochloride may prevent or treat chills or
rigors accompanying granulocyte transfusions

153
Obtaining the Blood
 Procedure will vary for institutions
 Essential guidelines include:
 Startof infusion within 30 minutes of the time
the component is released from the blood bank
 Proper ID of the blood component and recipient
 Careful handling while in transit

154
Identification
 Accurate identification of the donor’s blood
and the intended recipient
 Single most important step in ensuring a
safe transfusion
 Identification when blood is issued
 Identification when blood is administered

155
Administration of Blood
 Final Inspection Before Issue:
 Blood container have attached label or tag
indicating:
 Intended recipients two independent identifiers
 Donor unit number or pool number

 Interpretation of compatibility tests, if performed

156
Administration of Blood
 At issue:
 Verify:
 Intended recipient’s two identifiers, ABO group and Rh
type
 Donor unit number and donor ABO group and Rh type
(if required)
 Interpretation of crossmatch if performed
 Special transfusion requirements
 Date and item of issue

157
Administration of Blood
 Time Limits for Infusing Blood
Components
 Within 4 hours
 Concomitant Use of IV Solutions
 Only Normal saline
 Lactated Ringers – No
 Drugs - No

158
Administration of Blood
 Filters
 Allblood components
must be administered
through a filter to remove
clots/debris
 Standard blood filters
 170 micron filter

 Microaggregate filters
 20 – 40 microns

 Leukocyte reduction filters

159
Administration of Blood-
Infusion Devices
 Basic Types
 Infusion Controllers
 Monitor flow by gravity
 Infusion Pumps
 Deliver solutions under pressure
 Could cause red cell hemolysis due to negative

pressure exerted

160
Administration of Blood
 Blood Warming
 Transfusions of cold blood at rates >100mL/minutes
associated with higher rate of cardiac arrest
(hypothermia)
 Types
 Coil of plastic tubing
 Electrically heated plates
Clinical Situations for Possible Use
 Neonatal exchange transfusion
 Plasma exchange
 Surgery
 Trauma
 Cold Agglutinin Disease
161
Return of Unused Blood
 Refrigerated components may not be
returned to inventory if they have been
warmed to more than 10C
 30 minute maximum allowable time out of
temperature monitored storage

162
Return of Unused Blood
 Reissue of Blood and Components
 Container closure has not been disturbed
 Components maintained at correct temp
 At least one sealed segment of the integral
donor tubing has remained attached
 Records indicate that component has been
inspected and is acceptable for reissue

163
Costs- Blood collection center
perspective
 Increased costs of producing a unit of blood
 Recruitingdonors
 Increased complexity and cost of testing
 Competing with other industries to retain qualified
personnel
 Increased regulatory requirements and voluntary industry
standards
 Screening and testing for HIV, AIDs, Hepatitis
 Safety measures, WBC reduction

164
Costs – Hospitals Perspective

 Purchase of blood
 Other significant
costs
 Labor
 Equipment and
supplies
 Laboratory
 Administration
 Overhead

165
Reimbursement
 “The financial risk to hospitals, as well as to hospital
departments, of potential underpayment for care
involving blood-related components and services
depends in part on the relative proportion of hospital
activity involving these components and services.
Hospitals that provide more blood-intensive care
relative to their total care will be at greater risk to
the extent that updates to the Medicare PPS fail to
account for cost increases in blood-related
components and services.” Transfusion –August 2003 Supplement

166
Blood Utilization Review
 Joint Commission on the Accreditation of
Healthcare Organizations (1961)
 American Association of Blood Banks
 Part of quality plan
 Code of Federal Regulations
 Qualify for Medicare reimbursement

167
Blood Utilization Review
 Blood usage audits/guideline development
 Blood usage trends
 Critical transfusion events
 Transfusion reactions
 Transfusion transmitted disease
surveillance
 Blood administration practice

168
 Blood Banking Case Study
 
Listed below is your current blood bank inventory at the Back of Bourke Hospital.
AS-1 RBCs

Group A POS O POS O NEG B POS

Number 10 15 5 4
RBC

Group A AB O

Number 15 4 10
FFP
 
For each of the following requests what would you issue
and crossmatch as required (assume each event independent) ?
1. Patient female 26 years, group AB NEG, 2 units of RBCs, 4 units of FFP

2. Patient male 54 years, group A NEG, 6 units of RBCs

3. Patient male 21 years, group ?, 6 units of RBCs, 6 units of FFP STAT

169
4. Patient female 4 years group B NEG, 3 units of RBCs
Question
Which one of the following units of RBCs is
acceptable to give to a Group B positive
recipient?
A. Group O positive
B. Group A positive
C. Group A negative
D. Group AB negative

170
Question
Which one of the following units of RBCs is
acceptable to give to a Group B positive
recipient?
A. Group O positive
B. Group A positive
C. Group A negative
D. Group AB negative

171
Question
Which one of the following units of Whole
Blood is acceptable to give to a Group B
positive patient?
A. Group O positive
B. Group O negative
C. Group B positive
D. Group AB positive

172
Question
Which one of the following units of Whole
Blood is acceptable to give to a Group B
positive patient?
A. Group O positive
B. Group O negative
C. Group B positive
D. Group AB positive

173
Question

Which one of the following units of FFP is

acceptable to give to a Group AB negative
recipient?
A. AB positive
B. O positive
C. O negative
D. A negative
174
Question
Which one of the following units of FFP is
acceptable to give to a Group AB negative
recipient?
A. AB positive
B. O positive
C. O negative
D. A negative

175