Blood and Blood Products

Video Transcript

Introduction to Blood and Blood Products

By the end of this topic, you will be able to:

• Identify and explain the and blood products provided to the patient receiving the critical
care

• Explain the cryoprecipitated anti-hemophilic factor.

Transfer of tissues from a healthy person to a patient with therapeutic intent began with the
development of blood transfusion. This life-saving measure has progressively been the subject
of study, with an increasing body of scientific knowledge and techniques of scientific
exploration. Patients in critical care units, by their nature of the illness, form a large group of
potential recipients of blood prescriptions.

Anemia is a common issue when patients are admitted to the intensive care unit or ICU, and
packed red cells transfusion one among the most frequent intensive care unit interventions.

Let’s now look at the indications for red blood cells transfusion in critically ill patients.

Acute blood loss following trauma, gastrointestinal tract hemorrhage, surgery, among
alternative causes of anemia, are indications for red blood cells transfusion in critically ill
patients. Numerous studies have shown that approximately two-thirds of critical patients
admitted to an intensive care unit have a Hb concentration of less than 12 grams per decilitre
on the day of admission, and 97% of the patients become anemic after a week in intensive care
unit. The management of anemia and its effect on critically ill patients has been a serious issue,
and recently, blood product transfusion policies are modified from liberal transfusion to
restrictive transfusion.

Now let’s have a closer look at blood and its components

Whole Blood is the blood collected from a standard blood donation. A blood component is an
element of blood, separated from whole blood, such as red cell concentrate, platelet
concentrate, Free Frozen Plasma or FFP and cryoprecipitate which is prepared from the fresh
frozen plasma; rich in Factor VIII and fibrinogen.

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 Blood and Blood Products

WHOLE BLOOD is described as 450 milliliters of whole blood in 63 milliliters anticoagulant‐

preservative solution. It has Hemoglobin concentration of approximately 12 grams per decilitre
and hematocrit or Hct 35 to 45% with no functional platelets or labile coagulation factors like 5
and 8 when stored at +2° Celsius to +6° Celsius.

• it is capable of transmitting agents present in cells or plasma which was undetected during
routine screening for transfusion transmitted infections like HIV, hepatitis B & C, syphilis,
and malaria.

• It is stored Between +2°C and +6°C in an approved blood bank refrigerator, fitted with a
temperature monitor and alarm.

• Indications include:

• Red cell replacement in acute blood loss with hypovolemia and

• Exchange transfusion

• Contraindicated in risk of volume overload in patients with:

• Chronic anemia and

• Incipient cardiac failure

• While administrating the whole blood, ABO and Rh compatibility test with the recipient is a
must

• Should not add medication to a unit of blood

• Complete the transfusion within 4 hours of commencement.

A plasma derivative is made from human plasma proteins which are prepared under
pharmaceutical manufacturing conditions. These include:

• Albumin

• Coagulation factor concentrates and

• Immunoglobulin

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 Blood and Blood Products

Red Cell Concentrates

• Red Blood Cells consist of erythrocytes concentrated from whole blood donations by
centrifugation or collected by apheresis method.

• Packet with 150‐200 milliliters red blood cells from which most of the plasma has been
removed. Hemoglobin concentration will be approximately 20 grams per 100 milliliters
which is not less than 45 grams per unit and Hct by 55‐75%.

• Capable of transmitting an agent present in cells or plasma which was undetected during
routine screening.

• A dosage of one unit of good Red Blood Cells will build the hemoglobin level in a normally
estimated grown-up who isn't draining or hemolyzing by around 1 gram per deciliter or
hematocrit by 3%.

• In neonates, a measurement of 10-15 milliliters per kilogram are given.

• Red cell concentrates should be stored between +2°Celsius and +6° Celsius in an approved
blood bank refrigerator, fitted with a temperature monitor and alarm.

• Indications include:

• Red cell replacement in acute blood loss with hypovolemia and

• Exchange transfusion

• Contraindications are RBCs should not be utilized to treat sickliness that can be rectified
with a non-transfusion treatment.

• During Administration: Except if the beneficiary is bleeding or hemolyzing, and given the
transfused red cells are perfect, the post-transfusion hemoglobin can be evaluated from the
patient's blood volume, standard red cell volume and transfusion volume.

• Red Blood Cells can transmit Cytomegalovirus, mediating graft-versus-host disease and
causing febrile, non-hemolytic reactions.

• Platelet concentrates are set up from units of whole blood that have not been permitted to
cool underneath +20°Celsius and platelet concentrates might be provided as a pooled
unit. The occurrence of Bacterial contamination is around 1% of pooled units.

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 Blood and Blood Products

• The platelet concentrates might be stored up to 5 days at +20° Celsius to +24° Celsius.

• Measurements: One unit of platelet concentrate is given for 10 kilograms body weight; for
an adult of 60‐70 kilograms, 4‐6 single units containing no less than 240 x 109 platelets,
should raise the platelet count by 20 to 40 multiplied by 109 per liter.

• Indications include:

• Platelet function defects

• Thrombocytopenia

• Prevention of bleeding in bone marrow failure due to thrombocytopenia and

• Idiopathic autoimmune thrombocytopenic purpura or ITP

• Platelet concentrates are contraindicated in:

• Thrombotic thrombocytopenic purpura or TTP and

• Thrombocytopenia associated with septicemia, or in cases of hypersplenism

• Platelet concentrates after pooling should be mixed as quickly as time permits because of
the danger of bacterial multiplication. Contingent upon the state of the beneficiary, a unit is
ought to be transfused over time of not over 30 minutes.

• Febrile non-hemolytic and hypersensitive urticarial responses are normal, particularly in

patients accepting numerous transfusions.

Fresh Frozen Plasma or FFP is prepared from whole blood, either from the primary
centrifugation of whole blood into red cells and plasma or from secondary centrifugation of
platelet-rich plasma. The plasma is rapidly frozen to –25°Celsius or colder within 8 hours of its
collection and may contain normal plasma levels of albumin, immunoglobulin and Factor 8.

• Unit of issue is About 200-300 milliliters.

• Infection risk: FFP can transmit any agent present in cells or plasma which was undetected
by routine screening.

• An initial dose of 15-20 milliliters per kilogram is given. Further therapy is dependent on
clinical response and laboratory monitoring which includes Prothrombin Time or PT and
Activated Partial Thromboplastin Time or APTT.

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 Blood and Blood Products

• Definite indications for the fresh frozen plasma include:

• Immediate reversal of warfarin effect where prothrombin complex concentrate is

unavailable

• Replacement of a single coagulation factor deficiency

• Thrombotic thrombocytopenic purpura Inherited coagulation inhibitor deficiencies

where the specific concentrate is unavailable and

• C1 esterase inhibitor deficiency where the specific concentrate is unavailable

• Conditional indications for the fresh frozen plasma include:

• Massive blood transfusion

• Acute Dispersed Intravsacular Coagulation or DIC if there are any coagulation

abnormalities and the patient is bleeding.

• Liver disease, with abnormal coagulation and bleeding – prophylactic use to reduce
PT to 1.6-1.8 x normal for liver biopsy and

• Cardiopulmonary bypass surgery – use in the presence of bleeding but where

abnormal coagulation is not due to heparin. Routine perioperative use is not
indicated

Cryoprecipitated Anti-Hemophilic Factor or Cryo‐AHF

• Cryo-AHF is prepared from FFP by collecting the precipitate formed during controlled
thawing at +4°Celcius and re-suspending in 10 to 20 milliliters plasma.

• It is stored at -25°Celsius or colder for up to 1 year after the date of phlebotomy.

• Infection risk:

• As for plasma, but a normal adult dose when few packets are given, it involves
exposure to at least 6 donors.

• An Initial dose of 10-15 packs or 1.5-2.0 packs/10 kg body weight is given.

• Here are the indications to use Cryo‐AHF.

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 Blood and Blood Products

• It is used as an alternative to Factor VIII concentrate in the treatment of inherited

deficiencies of:

• Von Willebrand Factor or von Willebrand's disease.

• Clotting Factor VIII hemophilia A

• In acquired coagulopathies, it is used as a source of fibrinogen and

• Can also be used in isolated Factor XIII deficiency

• The contraindications are not to transfuse cryoprecipitate unless laboratory studies confirm
deficiency of a specific clotting protein for which this component is indicated

• Administration:

• Use of ABO-compatible product

• Infusion to be done as soon as possible after thawing

• Transfusion within 6 hours of thawing is a must

• Precautions:

• Cryo‐AHF must be transfused within 4 hours if it is an open system or units have

been pooled after thawing

• Cryoprecipitate pooled prior to freezing requires no extra diluent

Blood is considered as a lifesaving liquid organ. Each blood component is used for a different
indication. The blood components may produce adverse reactions causing mild allergic
manifestations to fatal reactions. To avoid and reduce such complications, blood products are
modified as leukoreduced products, irradiated products and so on.

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 Transfusion Reactions

Video Script

Transfusion Reactions

By the end of this topic, you will be able to:

• List the common adverse transfusion reactions

• Discuss the adverse effects of the blood transfusion and

• Discuss the precautions of blood transfusion to avoid transfusion reactions

Blood transfusion is a life-saving therapy. It is also associated with numerous adverse effects.
An adverse reaction is an unwanted response in a patient, temporally associated with the
administration of blood or blood component. Around 1% of all transfusions can result in some
adverse response. Serious complications of blood transfusion are related to infectious diseases
transmission. The most serious causes of the transmitted agents are HIV and Hepatitis B and
C. Blood should be set up for transfusion within 30 minutes of leaving the laboratory. Unused
blood from the theater or wards ought to be returned quickly (inside 30 minutes) to the
laboratory.

A transfusion response or reaction is an adverse event associated with the blood transfusion.

Transfusion responses can be caused by immunological or non-immunological mechanisms.

Immunological Reactions occur due to the mismatch or incompatibility of the transfused
product and the recipient. Immunological Reactions include:

• Hemolysis, immediate or delayed, involving Red blood cells -

• Febrile reactions, pulmonary infiltrates involving white blood cells -
• Post-transfusion purpura involving platelets
• Anaphylactic shock and urticaria involving plasma proteins and
• Graft versus host disease

Non-immunological reactions can be due to bacterial contamination, circulatory overload, and

physically or chemically factors. Nonimmunological Reactions include:

• Disease Transmission (HIV, Hepatitis B and C, syphilis and malaria.)

• Septicemia

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 Transfusion Reactions

• Air embolism

• Fluid overload and

• Iron overload

Now let us understand the Adverse Effects of Blood Transfusion.

The adverse effects of blood transfusion include:

• Acute hemolytic transfusion reaction or AHTR

• Delayed hemolytic transfusion reaction
• Febrile non-hemolytic transfusion reaction
• Hypersensitive (urticarial) responses:
• Anaphylactoid or anaphylactic reaction
• Transfusion-related acute lung injury or TRALI
• Transfusion-associated graft-versus-host disease and
• Transfusion-associated circulatory overload or TACO

Let’s understand each of these complications in detail.

Acute hemolytic transfusion reaction

These reactions are due to the preformed antibodies to the incompatible product and ABO
incompatible. Symptoms include chills, fever, hypotension, hemoglobinuria, renal failure, back
pain, disseminated intravascular coagulation or DIC. Intravenous or IV infusion should be given
with normal saline and urine output should be monitored greater than 1 Milliliter per kilogram per
hour.

Delayed hemolytic transfusion reaction

Anamnestic immune response to incompatible red cell antigen. May present with fever, jaundice,
falling hemoglobin, newly positive antibody screen in the blood bank. Occurs 1 to 2 weeks after
transfusion. Identify offending antibody in the blood bank. Transfuse when necessary with
compatible RBCs or red blood cells.

Febrile non hemolytic transfusion reaction

Due to preformed hostile to WBC antibodies in beneficiary. Risk is limited with leukocyte-reduced
components. Greater than or equal to 1°Celsius or 2°Fahrenheit ascent in temperature inside 2

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 Transfusion Reactions

long stretches of the beginning of transfusion with no other clarification for fever. Acetaminophen
premedication if responses are repetitive.

Hypersensitive (urticarial) responses

This type of reaction is present along with urticaria, pruritus, flushing, gentle wheezing. Stop
transfusion, use of antihistamines should be controlled; may continue transfusion if response is
settled, if not report response to blood donation center and consult treating physician.

Anaphylactoid or anaphylactic Reaction

Caused by an immune response to benefactor plasma proteins (Immunoglobulin A, haptoglobin,

C4). Symptoms includehypotension, urticaria, bronchospasm, angioedema, uneasiness
Treatment is with epinephrine (0.2 to 0.5 millimeters subcutaneous), antihistamines and
corticosteroids.

Transfusion-related acute lung injury

These are caused due to preformed HLA or neutrophil antibodies in donor. Symptoms include
hypoxemia, hypotension, reciprocal aspiratory edema, transient leucopenia, and fever. Treatment
involves providing respiratory and circulatory support depending on clinical severity.
Corticosteroids and diuretics (for pulmonary edema) have not shown benefit in this condition.
Majority of the patients improve within two to three days.

Transfusion-associated graft-versus-host disease

These are rare, but have high fatality rates between 90 to 100. Donor lymphocytes in transfused
blood mount an immune destructive response against recipient tissues. Symptoms include
pancytopenia, maculopapular rash, diarrhea, and hepatitis. Immunosuppressive and
immunomodulatory agents are used as treatments, while some patients require stem cell
transplant.

Transfusion-associated circulatory overload

Seen in approximately 1% of transfusions. New onset or exacerbation of acute respiratory

distress (dyspnea, orthopnea, count) 3 to 6 hours after transfusion. May be associated with
elevated brain natriuretic peptide, elevated central venous pressure, left heart failure, positive fluid
balance, pulmonary edema on chest x-ray. Risk factors include cardiac or renal dysfunction,
female gender, age greater than 60 years, severe anemia with volume expansion, positive fluid

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 Transfusion Reactions

balance, transfusion of multiple products. The mortality rate is about 1.4 to 8.3%. Management
includes stopping transfusion and other fluids, make the patient sit in upright position,
supplemental oxygen, and diuretic therapy.

Let’s now understand the precautions that need to be followed while transfusing blood.

All the transfusions should be given under the supervision of a clinician.

The patient should be observed nearly for the initial 15 minutes of the transfusion since it is
during this period that genuine hemolytic transfusion responses would first be able to be
distinguished.

The transfusion should be regulated to a maximum of four hours, with observing of the
imperative signs by the nursing staff at regular intervals.

Any change in crucial signs that is temperature, beat, respiratory rate, circulatory strain or level of
awareness might be a sign of a transfusion response. Proper care is needed if transfusion
response includes pruritus, palpitations, lumbar torment, torment along the section vein, fever,
hypotension, tachypnoea, tachycardia, and modified level of awareness.

The transfusion reactions are responsible for causing most serious adverse reactions or events.
Awareness about various clinical features of acute transfusion reactions with an ability to assess
the serious reactions on time can lead to a better prognosis.

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