Moderator

Dr. T.Pensi (Professor)

Dr Sunit Pathak(SR)

Presented by .Dr Vivek Gupta

• Transfusion of specific parts of

blood, rather than whole blood

• One donated unit can help

multiple patients

– Conserves resources

– Optimal method for transfusing

large amounts of a specific

component

Blood component therapy

OVERVIEW

What are blood components?

What to transfuse?

General issue in transfusion.

Indication of transfusion ?

How to transfuse ?

What to expect after transfusion ?

What can go wrong with transfusion ?

CONSTITUENTS OF BLOOD

Cellular components

Plasma

WHOLE BLOOD

PLATELET POOR

PLASMA

PLATELET RICH

PLASMAPACKED RBC

PLATLET CONCENTRATE

LIGHT SPIN AT 20-24 deg C

PREPARATION OF COMPONENT

HEAVY

SPIN

WHOLE BLOOD

P RBC Plasma

Light spin at 4

degree

PRBC

Heavy spin at 4

degree

Rapid freeze -70

deg C

Rapid thaw 0-6

deg

Cryo –poor

plasma

Plasma

Cryo

precipitateFFP Albumin

Buffy coat

granulocyteFreeze at -70

deg C within

6hr

PREPARATION OF COMPONENTS

Blood component Blood derivatives

How prepared Prepared by single

donation by blood bank

like freezing

/centrifugation

Prepare by large pool

donor by

fractionation and

purification

Compatibilty test Required Not required

Eg RBC,Platelet,Granulocyt

e

Albumin ,

immunoglobulin,

coagulation factor

concentrate

What can be transfuseEither standard products (like whole blood, packed red cells) or

specialized ones like (saline washed red cells or frozen red cells).

The various options available for blood component therapy are : -

1. Cellular components

•Red cell concentrate and leucoreduced red cell concentrate

•Platelet concentrate

Granulocyte concentrate

2. Plasma components

•Fresh frozen plasma

•Cryoprecipitate

•Cryo poor Plasma

3. Plasma derivatives (commercial preparations)

•Albumin (5% & 20%)

•Factor VIII concentrate

•Fibrinogen

•Immunoglobulins

•Other coagulation factors

.

Terminology

• One whole blood unit : 350ml

blood/450mlwith14mlCPDA/100ml of

blood) of whole blood in the original

collection bag is referred to as one whole

blood unit

.

• One component unit : Each component

made from that unit is defined as one unit of

that component.

• Each whole blood unit constitutes approx

10% of a donors blood volume.

General measure for blood transfusion

Things to do before administering blood products

1. Donor blood and recipient identification

2. check the compatibility label.

attached to every blood pack with following information

patient name

hospital reference number

patient ward

patient ABO and Rh group

expiry date

date of compatibility test

blood group of blood pack

What to check in the blood pack

1. Sign of haemolysis in the plasma .plasma become

pink(indicate that either blood is contaminated /allowed to

freeze/too warm)

2. Sign of hemolysis on the line between the red cell and

plasma

3.change in color in the red cell (darker/purple or black

color ) indicative of contamination

4 .any clot

5. The patient ‘s identity and blood pack before

transfusion

don’t administer the transfusion if blood pack appear

abnormal or damaged or it has out of refrigerator for longer

than 30 min .

Infusion set• Transfused through BT set with inbuilt filters of standard size 170-

260 mm (helps removes microscopic clots, cellular debris,

undesirable particles).

• IV sets should not be used (no filter)

Blood warming• Routine warming is not needed

.

• As blood flows drop by drop, it attains body temperature quickly.

Warming is indicated in• Children being infused @>15 ml/kg/hr

• Infants receiving exchange transfusion

• Patients with cold agglutinins

Methods of heating• Water bath with warming coil

• Dry heat warmer

• High volume heat exchanger

• Blood should never be wormed in bowl of hot water(haemolysis)

In what duration tranfusion should be completed.• There is risk of bacterial proliferation and loss of function in

blood product once they have removed from correct storage

condition.

Time limit for infusion

Start infusion Complete infusion

Whole blood/ within 30 within 2 hour

Red cells minutes (4hr in unstable eg. CHF)

Platelet conc. Immediately within 30 minutes

Fresh Frozen As soon as within 30 minutes

Plasma possible

• Patient monitoring

DON’T left unattended while transfusion is on

Sever reaction (MC during initial 15 min of transfusion)

Monitor the patient at starting of transfusion ,15 min of

transfusion , at least every hour of transfusion ,at end of transfusion ,

at 4hr of end of transfusion.

Encourage the patient to notify any reaction as shivering, flushing

, pain ,shortness of breath, begining to feel anxious.

What to write on the blood transfusion notes

Record . Identity of patient /blood pack /compatibilty label/Time of

transfusion started/completed/volume and type of product/donor

number/any adverse reaction

Vital .appearance/temperature/pulse/respiratory rate / fluid

balance(input /urine out put)/BP

Addition of drug and medications to blood bag / Blood set

• Is prohibited except normal saline; however this should be

done in blood bank.

• The same IV line should not be used for any other IV

solution except NS

• 5% dextrose results in haemolysis .

• Ringer lactate causes clotting of blood in the tubing.

• Addition of drugs may cause a change in the blood or a

change in drug can occur because of pH and ionic molecular

constituent.

• transfusion circuit should be closed. Once the bag has been

punctured by BT set( blood is brought to the tip of the tubing,

which must be connected directly to venous access device. This

would constitute closed circuit)

Don’ts for blood transfusion• Don’t delay initiation of blood transfusion.

• Don’t use routine pre transfusion medications.

• Don’t add any medication to blood bag.

• Don’t use unmonitored refrigerator for storage.

• Don’t use transfusion set for more than one blood bag.

Red blood cell

• Whole Blood

• Packed Red Cells

• Leukoreduced

• Irradiated

•Frozen thawed

Whole blood transfusion

.Viable for 35 days for transfusion (with preservative used being

CPD-A).

FRESH BLOOD :- when whole blood /its component is used within

1 day of collection

Disadvantage – Use of freshly drawn whole blood is a

vestige of the old transfusion practice .

Processing donor blood, which includes typing for ABO &

Rh antigens, antibody screening tests of HBsAg, antibody to

HIV virus and syphilis is rarely completed in 24 hrs.

Thus, tests are no valid indications for transfusing fresh

whole blood before completing all necessary tests.

SPECIAL RECOMMENDATION FOR INFANT:-

• Whole blood stored upto 72 hrs is the ideal component for

exchange transfusion in neonates.

• Infants tolerate whole blood less than 7 days old which has

plasma electrolyte concentration within acceptable normal limits

and adequate 2,3-DPG.

Indication of whole blood transfusion:-

• Exchange transfusion(DVET) in neonate

• Acute Massive blood loss(>25% in children and >10% in neonate)

• Hyperleucocytosis in acute leukemia (with WBC count > 100×109/L)

• Non availability of blood component

( IAP speciality series on hemato-oncology 2006)

WHEN TO TRANSFUSE:-

• when a patient requires both replacement of circulatory volume and

increase in O2 carrying capacity.

• Where specific component is not available

WHEN NOT TO TRANSFUSE:-• Though transfusion of whole blood is the simplest way to infuse

plasma and red cells simultaneously, it is not always advisable to use

whole blood in MILD- MODERATE BLOOD LOSS.

(This is so because the concept that stored whole blood is closest in

composition to the fluid that has been lost is not true and the choice

of transfusion of whole blood may be harmful as well as

uneconomical).

So alternatively blood volume can be restored early with the infusions

on non O­2 carrying solutions (either colloid or crystalloid) and the

restoration of circulating hemoglobin can be accomplished with

packed red cell transfusion (But this does not provide much

replacement of plasma proteins, so in extensive hemorrhage

clinicians prefer to give whole blood

How much to transfuse

• Amount of whole blood transfused is10- 20ml/Kg.

• For exchange transfusion, we use 2 x vol of neonate

blood (i.e. double the blood volume).

FACTS OF WHOLE BLOOD :-

• Almost 90% of platelets and 40% factors and activity are lost

within 24 hrs at temp of 1-60°C

• .

• Granulocytes begin to loose their phagocytic and bactericidal

properties within 4-6 hrs.

• RBC have about 80% post transfusion viability on storage in

CPD-A solution for 35 days.

• Following transfusion, half of 2,3 DPG levels regenerate in3-8

hrs while complete restoration of 2,3-DPG takes about 24hrs.

• Plasma of stored blood is equivalent to 5% albumin as a volume

expands.

What can GO wrong after whole blood transfusion

• Apart from usual complications, there may be deficiency of labile

clotting factor and platelets after massive transfusion.

• To prevent this, following can be transfused –

• FFP (1unit for 3-5 units of whole blood)

• Platelets (6 units of platelet concentrate for 10 units of whole blood)

• During double volume exchange transfusion hypocalcemia (due to

citrate ) ,which can be prevented by IV administration of Ca

gluconate (@2ml/Kg).

Special points to be remembered for whole blood transfusion

• Start the transfusion within 30 minutes of receiving the blood

(otherwise return it to blood bank)

• Once the temperature has crossed 10°C it cannot be restored .

• Transfusion must be completed in 4 hrs. (risk of bacterial

contamination)

PACKED CELL TRANSFUSION

Red blood cell/ packed cell transfusion

• Concentration of RBC depend on method of preparation .

•Sedimented cells : have PCV of 60-70%

•Centrifuged cells : have PCV of 80%

•Centrifuged cells with buffy coat expressed out : have PCV of >90%.

• Shelf-life:

– 21 days (CPD)

– 35 days (CPDA-1)

– 42 days AS-1

Component of choice to restore /maintain O2 . carrying capacity with

minimal expansion of blood volume

Advantages over whole blood :-

• Due to removal of plasma :

• Decrease in amount of electrolyte and ammonia and in

beneficial in patient with incipient CHF (Na+), renal failure

(due to K+ & acid) or hepatic failure (due to ammonia and

citrate).

• Chances of allergic /anaphylactic reactions are minimized.

• Decrease in amount of anti-A and anti-B normally present

in blood of individuals lacking corresponding antigen. This is

of value when it is necessary to use O group blood for recipient

of other blood groups.

Guidelines for packed red blood cells (PRBCs)

Transfusion(neonate)

Thresholds for preterm neonates

Less than 28 days of age and

1. Assisted ventilation with FiO2 more than 0.3: Hb 12.0 gm/dL or

PCV less than 40%

2. Assisted ventilation with FiO2 less than 0.3: Hb 11.0 g/dL or PCV

less than 35%

3. CPAP: Hb less than 10 gm/dL or PCV less than 30%

More than 28 days of age and

1. Assisted ventilation: Hb less than 10 gm/dL or PCV less than 30%

2. CPAP: Hb less than 8 gm/dL or PCV less than 25% red cell transfusion in

neonate

Any age, breathing spontaneously and

1. On FiO2more than 0.21: Hb less than 8 gm/dL or PCV less than

25%

2. On Room Air: Hb less than 7 gm/dL or PCV less than 20%

(AIIMS NICU PROTOCOL 2008)

A. Asymptomatic with Hb < 7 gm with low retics/ Symptomatic anaemia with with Hb < 10 gm:

1. On <35% hood Oxgn/ nasal cannula

2. CPAP / IMV with MAP < 6cm water

3. Apnoea/bradycardia,tachypnoea/tachycardia.

4. Poor wt gain

B. Hb < 12 gm:

1. On >35% oxgn hood

2. CPAP / IMV with MAP > 6-8

C. Hb < 15 gm:

1. Cynotic CHD

2. ECMO ( IAP guidelines 2006)

RBC transfusion < 4 month of age

> 4 mnths of ageA. Blood loss:

> 15% total body volume/ with hypovolemia

B. Hb < 8gm

1. Symptomatic perioperative anaemia

2. Chemotherapy/radiotherapy

3. Chronic congenital/acquired anaemia

4. Emergency surgery with anticipated bld loss

5. Uncorrectable preoperative anaemia

6. Severe infection

C. Chronic transfusion dependent states:

1. Thalassemia and other hemoglobinopathies

2. Bone marrow failure states

D. Patient in overt or impending CCF due to anemia (IAP guidelines 2006)

Transfusion dependent anemias/Thalassemias

Every 3-4 wks ,maintain pre transfusion Hb 9.5-10.5gm% &

post transfusion Hb 13-13.5%.

Pediatrics Oncology( May be done acc.to protocol):

1.Hb < 8 gm% and/or symptomatic anemia

2.Maintain Hb%>10 gm if intensive chemotherapy is due.

3. Febrile neutropenia

4.Thrombocytopenic bleeding

5.Hyperleukocytosis ( Partial exchange preferable)

Special situations

How much to transfuse

• Standard transfusion volume : 10ml/kg(maximum 15ml/kg in

hemodynamicaly stable).

• In severe anemia (Hb<5gm%), child should receive multiple

small transfusions of 3-5ml/kg over 3 hrs.

• A partial exchange transfusion is recommended when there is

overt CHF.

Advantage : Anemia is corrected rapidly and isovolumically.

Factor determining RBC transfusion

•Cardorespiratory status of patient.

•Cause and anticipated course of underlying anemia.

•Alternative therapy such as iron and recombinant EPO.

What to expect after transfusion

• Each 8ml/kg of RBCs in children and 3ml/kg in infant is

expected to raise Hb by1gm% and Hct by 3%.

• In actively bleeding, the response cannot be assessed by blood

count or Hb; accurate assessment is made by monitoring CVP.

Modifications of packed cells

A) Leucocyte poor RBCs

• LR contain <70% of original WBC and retains 70 % of

the original red cells

• Reduces febrile reactions

• Reduces HLA immunization (e.g. transplant)

• Effective in reducing CMV transmission (CMVsafe)

• Cellular immune function preservation

• Does NOT prevent GVHD!!!

• Methods to remove WBC,

Average depletion of

Leucocytes Platelets Red cells

Centrifugation 80 80 20

Filtration

Microaggrigate filters

Specific leucocyte dipleting filtre

40-50

95-100

40

90

None

10-12

Saline washing85 95 15

Freezing and deglycerolisation

(expensive)

98 100 10

.

• Mostly filters are used in laboratory to filter blood

before issue, some have designed sets for bedside

use like R-500, Pall RC 50 and RC100.

Clinical conditions which benefit from

leucoreduction

Thalassaemia major

Aplastic anaemia

Sickle cell anaemia

Leukaemia

Patients for organ transplantation

Patients on Dialysis

Patients with multiple/chronic infections

B) Frozen RBCs

• Red cells can be frozen in glycerol and stored at subzero

temperature for as long as 10 years.

Advantages :

• long term storage for use in patients with rare blood groups

especially in the form of autologous transfusion.

.

• Use of frozen thawed and deglycerolised blood prevents non

hemolytic febrile reactions in patients sensitized to WBC,

platelets or plasma proteins.

• It also prevents sensitisation against HLA antigens .

Irradiated Blood Components

Gamma irradiation of component

Inactivates donor lymphocytes to prevent Graft Vs. Host disease

(GHVD). Only accepted method.

Expiration date: 28 days (RBCs) from irradiation or original

outdate - which ever comes first.

Irradiated Blood Products- Indications

Congenital Immunodeficiency's: SCID, DiGeorge Syndrome

Bone Marrow Transplan

Intrauterine Transfusion of Fetus

PLATELET

Platelet transfusion

Platelet rich plasma

• Platelet concentrate

Types of platelet concentrates : –

• Random donor platelets (RDP) : Prepared from donated blood

within 4-6 hrs of collection by centrifugation and it contains

approx 5.5×1010 platelets.

• Single donor platelets (SDP) : are prepared by plasma apheresis

.

One unit of SDP : 5-10 units of RDP

One unit PC prepared from 450 ml of

whole blood contains at least 5.5×1010

platelets in 50ml plasma. One unit of PRP

has the same amount of platelet in 250ml

plasma.

Platelet transfusions

The indications for transfusion in children with quantitative and

qualitative platelet disorders are similar to those for adults but

neonates and infants <4mth from a special group and may need

platelet support at even higher platelet counts.

Decision making in platelet transfusions

Decision to transfuse platelets depends upon :

• Platelet count and function

• Clinical condition of the patient

• Cause of thrombocytopenia(marrow failure/ITP)

• Comfort level of treating physician

THERAPEUTIC PT PROPHYLACTIC PT

Thrombocytopenia + life

threatening bleed( intracranial,

malena, gum bleed , sever

menorrhagia )

Not very much

recommended dictim is if

no bleed don’t transfuse .

Platelet transfusion not

indicated for bleed like petechial

/ purpura/ echymosis

Thrombocytopenia <50,000

life threatening bleed is <1%

Transfuse at platelet count

<10,000 associated with

sepsis, fever, amphotericin B

therapy

Guidelines for pediatric platelet transfusion

Children and adolescents platelet count (×109/L)

• Platelets < 50 and bleeding

• Platelets < 50 and invasive procedure

• Platelets < 20 and marrow failure with hemorrhagic risk factors .

• Platelets < 10 and marrow failure without hemorrhagic risk factors.

• Platelets at any count, but with platelet dysfunction plus bleeding, or

invasive procedure.

Infants within first 4 months of life (×109/L)

• Platelets < 100 and bleeding

• Platelets < 50 and invasive procedure

• Platelets < 20 and clinically stable

• Platelets < 100 and clinically unstable.

• Platelets at any count, but with platelet dysfunction plus bleeding, or

invasive procedure.

(iap speciality series hematology and oncology /nelson test book of pedatrics 18 edition)

Recommendations for platelet transfusion during infancy

• Sick Preterm :-goal is to keep platelet >50,000/cu mm.

.

Most neonatologists use a platelet count < 50,000/ cu mm as a

transfusion trigger in these circumstances

• platelets should be transfused to any neonate whose platelet count is

<20,000 / cu mm.

• Currently, there are no alternatives to platelet transfusion to treat

thrombocytopenia in neonates.(nelson testbook of pediatrics /mannual of neonatal care 6th edition )

Some important point in thrombocytopenia

Bone marrow aspiration and biopsy can be performed with

sever thrombocytopenia

Lumber puncture,epidural anesthesia platelet count should be

raised to 50,000/cu mm.

Operation in critical situation brain /eye platelet count should

be >1,00,000/cu mm

Immune Thrombocytopenia platelet transfusion should be

reserve with life threatening bleed from G I tract / CNS bleed.

How to transfuse :-

• Do not store platelet in hospital refrigerator.

• Administer through a separate IV line.

• Begin with a slow infusion rate, if there is no reaction, infuse rapidlyso as to complete all platelets within an 30 min.

• Leucodepletion filter sets specific for platelet transfusion are availableand should be used in an affording patients.

Advantages of leucodepletion filter

• Prevents : FNHTR, Transmission of CMV infection..

What to expect after transfusion

• one unit of platelet concentrate raises the platelet count, 1hr

after transfusion, by 5000-10,000/ cu mm / sq.m BSA.

• Life span after infusion in few hrs to maximum 24 hrs.

What can go wrong after transfusion

A part from transfusion complications as detailed later following

can be expected.

• Due to storage temperature of 22°C, there is a higher risk of

FNHTR and bacterial contamination.

Dosage and administration :Standard dose 1 unit / 10 kg.For pediatric patients< 8 kgs, 5 ml/ kg - increase in

platelet count by 50,000/uLFor patients > 8 kg – 1 unit / 10 kg.

Facts about Platelet transfusion to be remembered

• Normal platelets express ABOAg on their surface : they do not

express RhD antigen .

• SDP donor should be of the same blood group.

• RDP of the same blood group is recommended (except in

emergency)

• Rh-negative women in reproductive age group should receive

Anti D if they receive RDP from Rh +ve donor, to prevent Rh

sensitization from contaminating RBs.

• Some amount of RBC contamination is inevitable(do cross

matching if repeated transfusion require)

• .There is no need to keep continuously shaking during the

transfusion.

Granulocyte

Granulocyte transfusion

• Use of recombinant granulocyte colony stimulating factor (G-

CSF) have made it possible to collect excessively large number of

normal neutrophils for transfusion into neutropenic patients who

have life threatening infections.

• must be ABO compatible with because contamination with red

blood cells.

• Prepared from a single donor using apheresis or manually

• contain at least > 1.0 x 1010 granulocytes

• Stimulated can yield 4-8 x 1010 granulocytes

• Stored at 24 deg C

• Infused within 24 hours of collection

Guidelines for transfusion neutrophils

children :

• Neutrophils < 500/ml + bacterial infection + unresponsive to

antibiotics.

• Neutrophils <500/ml + yeast or fungal infection progressing or

appearing during treatment with antimicrobials.

• Neutrophils dysfunction with bacterial, yeast, fungal infection

unresponsive to antimicrobials.

infants < 4 months

• Neutrophils<3000/ml + fulminant sepsis during the first week of life.

• Neutrophils <1000/ml + fulminant sepsis after the first week of life.

(IAP speciality series on hematology & oncology 2006)

Therapeutic approach

Course of treatment - Daily GTx for atleast 4 days is recommended.

- Treatment is based upon clinical judgement and the

response of the patients.

Dosage - Current standards require a minimum of 1×1010

granulocytes per concentrate and at least double this no.

is desirable.

- Neonates may receive upto 1×109

granulocytes/kg/day.

Timing of storage- stored for upto 24 hrs at room temperature without

agitation but show progressive loss of function with

storage and are therefore, transfused as soon as possible

after collection (usually within 6 hrs).

Transfuse within an hour of receipt from blood bank.

How to transfuse

• Transfuse through standard blood filter (don’t use leucoreduction

filter)

•Irradiate to prevent GVHD

FRESH FROZEN PLASMA

Fresh frozen plasma

• The volume from a single donation is about 200ml.

• Single donar plasma – plasma from a single donor, prepared byseparation form whole blood on or before the fifth day after expiry iscalled single donor plasma.

• For preparation of FFP, while collecting blood, the flow should berapid form the start and it is recommended that the total time taken tocollect 450ml of blood should not be more than 10 mins.

• FFP contains Factor 2,5,7, 8 , 9, 11 and fibrinogen.

• FFP should be administered within half an hour after thawing as the

activity of factor 5 and factor 8 are rapidly lost.

• FFP has self life of 1 year if kept at –30°.C

• Dose – Usually a dose of 10-15ml/kg weight is recommended at a

flow rate not exceeding 10ml/min.

• Indication –1).Replacement of coagulation factor in liver disease(abn coagulation

profile eighter prophylactic /control bleeding), deficiency of vitamin

K dependent factors (2,7, 9,10)eg HDN with bleeding , DIC with

bleeding, overdose of oral anticoagulants/ multiple coagulation

factor deficiency.

2.)Specific deficiencies of factors 5, 8 and 11. FFP is the only

available source for factor 5 . There is no factor 5 conc available

.

3.)Urgent replacement of missing hemostatic factor in bleeding

patients when specific concentrate preparations are not available as

in case of haemophilia A, Haemophilia B.4.) anticoagulant protein (protein C and S ) replacement

5.) plasma exchange replacement fluid for thrombotic thrombo -

cytopenic purpura

6) unknown facto deficiency

(iap guidelines 2006/nelson test book 18 edition )

Indication of FFP transfusion in neonate

1. Disseminated intravascular coagulopathy

2. Vitamin K deficiency bleeding

3. Inherited deficiencies of coagulation factors

rare indications include patients with afibrinogenemia,

vonWillebrand factor deficiency, congenital antithrombin III

deficiency,

protein C deficiency and protein S deficiency when specific factor

replacement is not available. It is also used for reconstitution of

blood for exchange transfusion.

FFP is not indicated for correction of hypovolumia or

immunoglobulin replacement therapy due to safer

alternative(albumin/saline /immunoglobulin)

CRYOPRECIPITATE

Cryoprecipitate

• Cryoprecipitate are precipitated proteins of plasma rich in

factor 8 factor 13 ,fibronectin , fibrinogen and von

willibrand factor.

• One unit of Cryoprecipitate contains (volume 10-20ml)

80 -120 unit factor 8

• ABO compatible unit is preferable . Rh compatibility

testing is not required.

• Usual dose is 2 unit / 10 kg ( IAP guidelines 2006)

• Indication for cryoprecipitate

1) Cryoprecipitate is used in moderate and severe hemophilia A

in the absence of factor 8

2) Von Willebrands disease .

3) Dysfibrongenemia, hypofibrinogenemia and consumptive

coagulopathies.

4) Intactable bleeding in uremia and platelet storage pool disease.

5) Congenital factor 13 deficiency.

( iap guidelines 2006/ nelson test book of pediatrics 18 edition)

May be beneficial in patients with septicemia or burns because of

fibronectin content.

Specific factor concentrates

• Specific factor concentrates include antihemophilic factor

concentrate (AHF), factor 8, and prothrombin complex.

• They can be stored at 6-8° for 2 years.

• Intermediate purity factor 8 concentrates contain 15-20 IU/ml. It

is the product of choice for moderate and severe hemopilia A.

• The dose and frequency of administration of these products

would need to be tailored to the severity of bleeding

manifestations is an individual patient.

Lesion Level of factor 8

desirable 15 min

after infusion

(IU/dl)

Factor 8

dose/kg

No. of infusions

required

Early hemartheosis

minor external bleeds

10-20 10-15 1-3 times 12

hourly

Severe hemarthrosis

internal haemorrhage

29-70 15-50 3-7 times 12

hourly then 24

hourly

Major surgery serious

accidents

70-100 50-70 12 hourly, until

normal bleeding

and rehabilitation

completed.

• If the facilities of factor assays are not available, PTT can be

used as a rough guide to factor 8 activity. If PTT is in normal

range, the factor 8 level is usually over 30%, if the PTT is

prolonged, factor 8 level will be generally low.

• Prothrombin complex when reconstituted contains 30-100 IU/ml

of all factors in it. It is recommended for replacement therapy in

hemophilia B (factor 9 deficiency) but may also be used for

congenital or acquired deficiency of factors 2, 7 or 10, and

bleeding in hemophiliacs with antibodies against factor 8.

• Antithrombin 3 concentrates are used for treating thrombotic

episodes in patients with congenital AT III deficiency in a dose

of50 units/kg body weight.

ALBUMIN

5% albumin k/a PPF(90%

albumin & 10% globulin) 20% albumin

Burn

Extensive surgery

Hemorrhagic shock waiting

for blood

Partial exchange

Nephrotic syndrome with

anasarca(.5 – 1gm/kg) f/b

diuretic within 15 min of

administration

PPF=plasma protein fraction

Immunoglobulins

Normal :-mix of IgG – obtain

by fractionation of plasma

(IV/IM)

Specific:- from donor with high

specific Ab against pathogen (IM)

Prevention & treatment of disease (hep B, varicella,measles,tetanus

,rabies)

Replacement therapy (Hypogamglobulinemia)

Immune disorder ( ITP, kawasaki disease, AIDP)

Myasthenia gravis,life threatening lupus

Sever sepsis in neonate

Prevention of sensitization in Rh neg women by administrating anti D

INDICATION

Complications of transfusion :-

The potential complications of blood transfusion therapy are many,

but most present problems only in patient requiring repeated or

large no. of transfusion.

Complications

Immunologic Non immunologic

Caused by stimulation of Ab production by foreign

alloantigen present on blood components.

Immediate

1. Hemolysis (due to Red cell

incompatibility)

2. Febrile, non hemolytic reaction (due to

Ab to leucocyte Ag)

3. anaphylaxis (due to Ab to IgA)

4. Urticaria (due to Ab to plasma protein)

5. Non cardiac pulm. oedema (due to Ab

to leucocyte or complement activation)

Delayed

1. Alloimmunisatoin

of RBC, WBC, platelet

Ag or plasma protein

2. Hemolysis

3. Graft Vs host

disease

4. post transfusion

purpura

Caused by physical or chemical properties of transfused blood

products as well as contaminating infectious agent.

Immediate

1. Fever with shock (due to

bact cont.)

2. CHF

3. Hemolysis (due to

physical destruction of RBC)

Delayed

1. Fe overload

2. Hepatitis

3. AIDS

4. Protozoal infection

5. Syphilis

6. Mononucleosis like effect.

Non immunologic

Blood components capable of carrying infective organism

1. Red cells - Malaria, Parvovirus B19, HIV

2. Leucocytes CMV, HTLV, HIV, HBV/HCV, EBV

3. Platelets HIV

4. Plasma HBV/HDV, HIV

Massive transfusion

• Definition : Massive transfusion is defined as transfusion of bloodequal to the patients blood volume within a period of24 hours.

• For massive transfusion, it is best to use blood that is not more than 7days old.

• Patients receiving massive transfusions are liable to certain specialcomplications, the most important of which are cardiac arrhythmias,which may proceed to ventricular fibrillation and cardiac arrest.

• Cause

• Excess of citrate which may cause a fall in ionised Ca2+

• Rise in serum potassium

• Fall in blood pH

• Cold blood

• Prevention

• Maintenance of adequate perfusion to prevent cardiac arrest.

• Careful warming of blood to body temperature

• Administration of Ca2+ gluconate (eg 1ml/kg of 10 percent Ca2+

per litre of blood after first two litres)

Bibliography

IAP Text book of pediatrics 4th edition

Nelson test book of pediatrics(18th edition)

Wintrobes’s Hematology 21st Edition.

IAP Specialty series on pediatric hematology and oncology.

(Under IAP president action plan 2006)

Recent advances in Neonatology (Publication of NNF)

Advances in pediatrics-1 (Indian Journal of Paediatrics)

Transfusion medicine technical manual (Makroo& Saran)

De-Gruchy’s clinical Hematology in Medical Practice, 5th Ed.

Workshop of hematology (Held in Mumbai Pedicon 2007 on 9th

Jan2007).

Guidelines for packed red blood cells (PRBCs)

Transfusion(neonate)

Thresholds for preterm neonates

Less than 28 days of age and

1. Assisted ventilation with FiO2 more than 0.3: Hb 12.0 gm/dL or

PCV less than 40%

2. Assisted ventilation with FiO2 less than 0.3: Hb 11.0 g/dL or PCV

less than 35%

3. CPAP: Hb less than 10 gm/dL or PCV less than 30%

More than 28 days of age and

1. Assisted ventilation: Hb less than 10 gm/dL or PCV less than 30%

2. CPAP: Hb less than 8 gm/dL or PCV less than 25% red cell transfusion in

neonate

Any age, breathing spontaneously and

1. On FiO2more than 0.21: Hb less than 8 gm/dL or PCV less than

25%

2. On Room Air: Hb less than 7 gm/dL or PCV less than 20%

Graft vs Host Disease

• It occurs in patients following transfusion who are severely

immunosuppressed, such as those being intensively treated with

chemotherapy and radiation.

• It is also a rare event in infants who receive intrauterine

transfusions followed by exchange transfusion for haemolytic

disease of new born.

• Mechanism : GVH disease occurs if donor functional

lymphocytes engraft and multiply. These engrafted donor cells

react against the foreign tissue of the host (recipient).

• Symptoms – Include fever, skin rashes, hepatitis, diarrhea, bone

marrow suppression and other infections.

• Outcome is usually fatal.

• Prevention – pre transfusion irradiation of all blood components

containing lymphocytes will prevent GVH disease. The

functions of red cells, granulocytes and platelets are not affected

by such irradiation; but irradiation slightly decreases the ability

of red cells to tolerate storage. For this reason it is recommended

that irradiated red cells not be stored for more than 28 days.

Irradiation is required for infants weighing less than 2kg. Blood

irradiators are capable of delivering 15-30GY over 1-5 minutes

per unit; this dose effectively inactivates immunocompitent T

cells.

j) Transmission of diseases

• syphilis, malaria and serum hepatitis were the three principal

problems recognized in relation to blood transfusion.

Hepatitis B – It is the major cause of post transfusion hepatitis.

• Screening of every blood donation for Hb and Ag is now mandatory.

• Hepatitis B has a mean incubation period of 63 days when

transmitted by blood transfusion.

• It may be transferred in cellular components as well as in cell free

suspension washing of red cells does not eliminate the risks of

transmission.

• The absence of HbsAg in the donor blood suggests but does not

exclude.

• Hepatitis can be transmitted by any of blood produces except

•Immunoglobulin preparation

•Heat treated albumin

•Plasma protein fractions

• Testing of blood for anti Hbc in addition to HbsAg would reduce

the incidence of HBV from HBsAg negative blood by about 50%.

Hepatitis C

• After the introduction of routine screening for hepatitis B, the

great majority of hepatitis following transfusion was found to be

related to non A, non B hepatitis (NANBH) ; hepatitis C virus has

been found to be the major cause of such cases.

• Hepatitis C can be transmitted by blood and blood products

including IVIg, albumin and factor VIII concentrates.

Cytomegalovirus

• Was first recognize as a cause of post transfusion pyrexia and

hepatiis in patients undergoing open heart surgery.

• Significance CMV induced disease is much more common in

recipients who are immunosuppresed.