PITFALLS

dalam PENYIMPANAN DARAH

Usi Sukorini
BASIC COURSE IN BLOOD TRANSFUSION
February, 7th, 2020
 ARTI PITFALLS

▪ ‘jebakan’

Pitfalls dlm penyimpanan komponen darah → hal

yang merugikan yang dapat mempengaruhi
penyimpanan produk darah dan akibatnya
BLOOD PRODUCTS
 Blood Composition

http://basicmedicalkey.com/blood/
 BLOOD PRODUCTS

Whole blood
• One unit of donor blood collected in a suitable
anticoaguulant-preservative solution and which
contain blood cells and plasma

Blood components
• A constituent separated from the WB, by differential
centrifugation of one donor or by apheresis

Blood derivatives
• A product obtained from multiple donor units of
plasma by fractionation
 BLOOD PRODUCTS

Cellular Plasma Plasma

components components derivatives
• Packed red cells • Cryoprecipitate • FVIII concentrate
• Granulocytes • Fresh frozen • FIX concentrate
concentrate plasma • Albumin
• Platelet • Immunoglobulin
concentrate • Prothrombin
complex
concentrate
BLOOD STORAGE
 PLATELET STORAGE

During • gently agitated

storage:
• Horizontal flatbed or elliptical rotators
• → to prevent pH from decreasing
below 6.2

• → alarm systems should also alert when

the agitator has malfunctioned
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB, 2011)
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB, 2011)
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB,
(AABB, 2011)
2011)
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB, 2011)
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB, 2011)
STORAGE AND EXPIRATION REQUIREMENTS FOR SELECTED
BLOOD COMPONENTS

(AABB, 2011)
PITFALLS IN BLOOD STORAGE
FAILURE TO MEET THE REQUIREMENTS

Pitfalls

• Failure to adhere to the storage and expiration

requirements could result in decreased
transfusion efficacy, potential harm to the
recipient, or both
PITFALLS IN BLOOD STORAGE

Pitfalls

RBC &
Platelet
storage
lesion
 STORAGE LESION

Definition:
• Series of biochemical and biomechanical changes
in RBCs or platelets ex vivo preservation that reduce
their survival and function
 RED CELL STORAGE LESIONS

• Erythrocytes are prone to modifications due to

• High oxygen environment (prone to oxidative stress and
hemoglobin auto-oxidation)
• Absence of nucleus and other organelles – no repair
mechanism

 Ex vivo storage of blood

 Non-biological containers at non-biological temperatures
 Changes in cellular biochemistry
 Change in normal ageing processes that cells undergo in
the body
 THE STORAGE EFFECTS OF RBC

Metabolic Oxidative
effects effects
RBCs
storage
lesions

Biomechanical
effects

Chen D, Serrano K and Devine DV., Introducing thr red cell storge lesions, ISBT Science Series (2016) 11 (Suppl. 1) 26-33
 RBCs storage lesions

Vani et al, Storage lesions in blood component, Oxid Antioxid Med Sci 2015, 4:3
Delobel et al., 2015
 The storage effects of RBC

METABOLIC EFFECTS

• Lack of mitochondria → only glycolisis for energy production

• Acidosis leads to
• inhibition of phosphofructokinase and hexose kinase
• slower glycolysis
• reduced ATP production
• Decreased glutathione reductase levels -> reduce the ability of
the RBC membrane to avoid oxidative damage

• The decrease in pH → breakdown of 2,3-diphosphoglycerate

• low level of 2,3-DPG leads to a left shifted oxygen disassociation
curve
• increase haemoglobin O2 saturation and affinity
Chen et al., 2016
 The storage effects of RBC

METABOLIC EFFECTS
• The major membrane Na+/K+ ATPase is inhibited at low
temperature
• continuous leakage of intracellular potassium
• Na+ entry in to cells
• K+ accumulation in storage solution
• Increase the risk of hyperkalemia-induced arrhythmia
• Specially in vulnerable patients
• Ex:- neonates, renal failure patients, massive transfusions
 RBCs storage lesion
BIOMECHANICAL EFFECTS

• Normal shape of the RBC is a

biconcave disc.

• Maximum surface area → efficient

gas exchange and flexibility to
travel through the capillaries
network and reticuloendothelial
system

• During storage → RBCs slowly

evolve from smooth biconcave
discs to spiculated echinocytes to
dense spheroechinocytes → RBCs
post transfusion survival reduce →
due to decreased surface to
volume ratio and deformability

Chen D, Serrano K and Devine DV., Introducing thr red cell storge lesions, ISBT Science Series (2016) 11 (Suppl. 1) 26-33
 RBCs storage lesion
BIOMECHANICAL EFFECTS

• Microvesicle (MV) release → is a

controlled process, stimulated by
pro-apoptotic signals, shear stress or
oxidative damage

• MVs (heterogeneous) → thrombotic

complication

• RBC microvesiculation →
Intravascular rupture of RBCs
 RBCs storage lesion
BIOMECHANICAL EFFECTS

• the sialic acid content of RBCs decreases with storage →

impaired tissue perfusion

• Phosphatidylserine (PS) translocation to the RBC surface

increases during storage → ischaemia
 RBCs storage lesion
OXIDATIVE STRESS

Under aerobic storage conditions:

• → RBCs are constantly exposed to a pro-oxidative
environment

• Any oxidative damage → repair by superoxide dismutase &

methaemoglobin
• Glutathione stores decline during storage → hydroxyl
radical formation increases

Chen D, Serrano K and Devine DV., Introducing thr red cell storge lesions, ISBT Science Series (2016) 11 (Suppl. 1) 26-33
Delobel et al., Storage lesion: History and perspectives, World J Hematol (2015) November 6; 4(4): 54-68
 RBCs storage lesion
OXIDATIVE STRESS

• During storage → RBCs undergo progressive oxidative insult to

proteins and lipids
• Spectrin damaged by progressive oxidative stress correlates
well to MV formation during storage

• Oxidative damage can also cause formation of

lysophospholipid → TRALI
• These observations suggest that RBC function and viability
deteriorate as the oxidative injury persists over storage.

Chen D, Serrano K and Devine DV., Introducing thr red cell storge lesions, ISBT Science Series (2016) 11 (Suppl. 1) 26-33
 PLATELET
STORAGE
LESION

Factor influencing the

development of
platelet storage lesion

Vani et al, Storage lesions in blood component, Oxid Antioxid Med Sci 2015, 4:3
 PLATELET STORAGE LESION

Vani et al, Storage lesions in blood component, Oxid Antioxid Med Sci 2015, 4:3
PLATELET STORAGE LESION
 STORAGE OF PLATELETS: EFFECTS ASSOCIATED WITH HIGH
PLATELET CONTENT IN PLATELET
STORAGE CONTAINERS

• A major problem associated with platelet storage containers is

that some platelet units show a dramatic fall in pH, especially
above certain platelet contents

• Exceeding the maximum storage capacity of the test platelet

storage container resulted in immediate negative effects on
platelet metabolism and energy supply, but also delayed
effects on platelet function, activation and disintegration

Gulliksson et al., 2012

Cold and agonist-induced platelet activation

Egidi et al, Blood Transfus 2010; Suppl 3:s73-s81

 PLATELET ACTIVATION

Egidi et al, Blood Transfus 2010; Suppl 3:s73-s81

PLATELET ACTIVATION
 PLATELET STORAGE LESION

• Prolonging PC shelf life at 22 °C for more than 5 days, other

than holding an increased bacterial contamination potential,
could also result in morphological changes that impair platelet
function

Egidi et al., 2010

 STORAGE TEMPERATURE MONITORING

• If an automated temperature recording device is not used,

then temperatures of the blood component storage
environment must be recorded manually every 4 hours

• 5.1.8.1.2 For storage of blood or blood components, the

temperature shall be continuously monitored or the
temperature shall be recorded at least every 4 hours (AABB,
2011)

• This requirement includes ambient room temperature

monitoring if blood components such as platelets are not
stored in a platelet chamber or incubator.
 TEMPERATURE REQUIREMENT DURING
TRANSPORT

• It is recommended that all red cell transport containers be

validated to maintain a temperature of 1 to 6˚C for a specified
period to ensure compliance with the transport and storage
requirements for Red Blood Cells
 EQUIPMENT FAILURE

• In the event that an equipment failure occurs and that the

failure prevents acceptable temperature ranges from being
maintained →
• the facility should have policies, processes, and procedures
in place to relocate the blood components.

• The secondary storage location:

• another on-site refrigerator or freezer,
• validated storage boxes or coolers appropriate for the blood
component
• potential prolonged storage time, areas in which the ambient
room temperature is monitored, or off-site locations.
 EQUIPMENT FAILURE

• Because the safety, quality, purity, and potency of the blood

components may be affected by delay in relocating to a
secondary storage location, → it is recommended that the
relocation occur before the upper or lower acceptable
storage temperature is exceeded.

• This can be accomplished by setting the alarm points of the

storage devices just short of the acceptable storage
threshold.
THANK YOU