Blood Component Therapy
 Blood Components
 Special Processing/Attributes
Irradiation
Leukoreduction, CMV Negative/CMV Safe
 Washing
 Volume Reduction


 Patient Safety
Type and Crossmatch Verification
Unit Verification
 Monitoring
 Transfusion Reactions


Mary Grabowski, RN, BSN, BSIA
PSBC Hospital Transfusion Safety Officer
Composition of Blood
 Reference Information
Whole Blood Collection
 ~ 55-60% Plasma
 ~ 40-45% Formed Elements:
Red Blood Cells (RBC)
Leukocytes (WBC)
Platelets
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Blood Processing Laboratory
Blood Components - Whole Blood
RBC
Platelet
WBCs
Plasma
WBCs
4 to 6 Pooled
for adults
Cryoprecipitate
1 Pool
(6 units/pool)
for adults
Pooled Platelets
(a.k.a. 4, 5, or 6 pack)
Pooling Platelets into One Bag
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Apheresis Collection
Apheresis Platelets
• Platelets
• Granulocytes
• Plasma
• RBCs
 One unit = 4 to 6 pooled
 Adult order - usually one
Apheresis or 4 to 6 pooled
 Only Apheresis are available
for emergency order
Red Blood Cells
Indications
Red Blood Cells
Therapeutic Effect
 Symptomatic anemia
 Severe bleeding
 General Guidelines:
Hgb / Hct
<7 / 21%:
Likely required
7-10 / 21-30%: Varies with clinical condition
>10 / 30%:
Unlikely required
 Average size Adult (per unit)
  Hgb ~ 1 gm/dL
=  Hct ~ 3%
 Dose: number of units given depends on
clinical situation
ONE and DONE!
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Platelets – Indications
 Prevent or treat bleeding due to:
 Thrombocytopenia
 Platelet dysfunction
 Prevent spontaneous bleeding in
patients with bone marrow failure:

Platelet count <10,000/l in clinically
stable patients
Platelets
Therapeutic Effect
 Apheresis Platelets
  ~ 30,000/l per unit
 Pooled Platelets


 Active bleeding or surgery:
 <50,000/l : general med/surg patients
 <100,000/l : eye surgery, neurosurgery,
massive hemorrhage, severe vascular
injury, diffuse alveolar hemorrhage
 ~ 7,000/l per each unit in pool
Example – 5 unit pool expect increment of 35,000/l
 Adult dose - usually:
 One Apheresis platelet
 or 4-6 pooled platelets
Plasma
Therapeutic Effect
Plasma Indications
 INR > 1.6 with one of the following:
 Adult: One unit  most coagulation
factors ~ 2.5%

Active bleeding

Urgent invasive procedure/surgery
required
 Dose based on clinical condition and
underlying disease process

Adult dose: 10-15mL/kg

Usually 3-6 units
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Cryoprecipitate
Indications
 Hypofibrinogenemia

Fibrinogen < 100 mg/dL

Fibrinogen < 125 - 150 mg/dl, if based on clinical
condition expected to fall significantly


Cryoprecipitate
Therapeutic Effect
 1 Pool (6 units/pool):
  fibrinogen ~ 45 mg/dL
 Adult Dose:
 1-2 units per 10kg (1 or 2 Pools)
Disseminated Intravascular Coagulation
Active bleeding
Cryoprecipitate = Fibrinogen
Granulocytes - Indications
 Preparation


Collected by apheresis machine
Always Irradiated
 Indications - Severe neutropenia with:
 Life-threatening
bacterial or fungal infection not
responsive to antimicrobial therapy
 Neonates with sepsis
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Granulocytes
Therapeutic Effect
Irradiation Process
 HOW
 Placed in Irradiator
 May or may not see increase in WBC count
 EFFECT- Inactivates Lymphocytes

 Dose
 Pediatrics:
max 20mL/kg/day
 Adults: 1 unit/day
Alters the genetic material

Prevents replication and ability to
attack the recipient’s tissue
Irradiation – Applicable Components
Irradiation - Purpose
RBC
Platelets
 Prevent
 Transfusion-Associated Graft versus Host Disease
WBCs
WBCs
 Similar to GVHD seen in BM/Stem Cell transplant
recipients
 Immunocompromised patients do not destroy the
infused lymphocytes in the blood component
Note: Granulocytes ALWAYS IRRADIATED


Lymphocytes engraft / proliferate
Attack host tissue
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Transfusion-Associated Graft Versus
Host Disease
 Lymphocytes launch attack against
 Skin, Liver, Gut
 Bone Marrow
 Clinical symptoms present
Transfusion-Associated Graft Versus
Host Disease - Outcome
 Outcome: ~ 90 % mortality
 Infectious complications
 Bleeding complications
 Death typically occurs 3-4 weeks post-transfusion
8-12 days post-transfusion
Fever
Skin - skin rash
 Liver - elevated LFTs, hepatitis
 Gut - diarrhea, anorexia, nausea/vomiting
 Bone Marrow - bone marrow failure (pancytopenia)

 No effective treatment

Transfusion-Associated Graft Versus
Host Disease
 Prevention is a must!
Irradiation Indications
 Patients with competent immune systems at risk
for TA-GVHD

* Components from blood relatives


See Handout for Specifics
No longer offered by PSBC
* HLA matched platelets
* ALWAYS irradiate above components for ALL patients
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Leukocyte Reduction
Applicable Components
Leukoreduction Process
 HOW
RBC

Pass component through
Leukoreduction filter at PSBC

Apheresis machine during collection
 Effect

Majority of the leukocytes removed
Platelets
WBCs
WBCs
PSBC
100% Leukoreduction of RBCs and Platelets
Note: Granulocytes NEVER Leukoreduced
Leukoreduction – Purpose
 Reduce unwanted effects caused by WBCs and
their by-products released during storage

Prevent Febrile Non-Hemolytic Transfusion
Reactions

Prevent Alloimmunization

Use as substitute for CMV negative components
Leukoreduction
 Prevent recurrent:
 Febrile Nonhemolytic Transfusion Reaction
 Cause – not completely understood

Antibody mediated


Patient antibodies react with infused WBCs
WBCs breakdown during storage
 Cytokines released into the component
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Leukoreduction
 Help prevent:

Alloimmune Platelet Refractoriness
 Alloimmunization
 Development of patient antibodies against donor HLA
antigens
Alloimmune Platelet Refractoriness
 Platelets also express HLA class I antigens
 Infused platelets destroyed by HLA antibodies
 Difficult to maintain an adequate platelet count
 WBCs contain human leukocyte antigens (HLA)
 30-50 % of multitransfused patients develop HLA
antibodies
Multiple Non-Leukoreduced Transfusions
HLA Antibody Development – 2 to 4 weeks later
Recipient antiHLA antibody
HLA
Class I
HLA Class II
HLA
Class I
HLA Class II
HLA Class I
Donor White Blood Cell
Donor White Blood Cell
Donor
Platelet
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Alloimmune Platelet Refractoriness
Multiple antibodies to
different HLA
antigens via multiple
transfusions with
non-LR products
Alloimmune Platelet Refractoriness
 Poor platelet count increment at 1 hour post
transfusion


Anti- HLA- A5
Premature
removal by
the spleen
HLA - A5
Transfused Platelet
No increase in
platelet count
Poor increment ~ < 5,000
Normal increment ~ 30,000 +
 Poor increments on at least 2 occasions in absence
 Obtain platelets counts
 Pre-transfusion
 1 hour post (10-60 min)
 PSBC do workup
 Patient – HLA antibodies
HLA Matched Platelets
 Donor’s HLA typing is matched to patient’s HLA
typing (HLA A, B) – as much as possible
 Apheresis - collect from matched donor
 Initial order often requires 48 hours notice
 Resource limited by donor pool
Leukocyte Reduction
 Reduce rate of HLA alloimmunization in organ
transplant patients/candidates
Renal
Heart
 Lung


 Risk of transplant rejection due to HLA antibodies
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Leukoreduction
 Creates CMV “Safe” Component
 Help prevent CMV transmission
CMV
(Cytomegalovirus)
 Herpes virus
 CMV lies dormant in tissues and circulating
leukocytes of infected individuals
 ~ 50 % of population in WA is CMV positive
 Poses little problems to those with competent
immune systems

CMV Safe Components
CMV Neg/Safe Components
 Purpose
 Prevent primary CMV infection in
immunocompromised CMV-negative patients
 Serious complications
 CMV-associated pneumonia, myocarditis, retinitis,
hepatitis, gastroenteritis
Most have no history of illness
 CMV transmission– reduced by use of either:

CMV Negative Components

Leukoreduced Components
 With 100% Leukocyte Reduction

Many facilities discontinued CMV Neg ordering option

LR substituted for CMV Neg
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CMV Safe Indications
Washing Blood Components
 How

See Handout for Specifics
Plasma is removed and cells are resuspended in NS
 Components

RBCs and Platelets
 Purpose - Prevent repeat anaphylactic reaction

Washed Red Blood Cell Unit
In patients with history of this reaction with prior transfusion
Volume Reduction
 How
 Component is centrifuged
 Majority of plasma removed
 Effect
 Plasma proteins/cytokines removed
 Volume reduced to ~ 100 ml (or other volume)
 Components
 Platelets
 Granulocytes
 Purpose - Prevent various adverse reactions
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Transfusion Safety
Critical Steps in Transfusion Process!
Volume Reduction - Indications
 Extremely volume sensitive patients at risk for
1) Collection and labeling of
volume overload
Type/Cross/Screen/Hold sample
 ABO plasma incompatible Apheresis platelets or
granulocytes
 Recurrent allergic reactions not made tolerable by
•
“Wrong Blood In Tube” can be fatal!
•
Two person verification at bedside
is recommended
pre-medications

If not successful, consider washing
2) Pre-Transfusion Verification
• Transfusing wrong unit can be fatal!
• Two person verification at bedside
is required before starting transfusion
 Recurrent febrile reactions not prevented by
leukoreduction

If not successful, consider washing
Verification of PSBC Blood Samples
(Type and Crossmatch, Type and Screen, Hold)
Verified by TWO Staff at BEDSIDE:
Patient Name, MRN and Birth date
ARMBAND
LABEL on TUBE
Type and Crossmatch Sample
 Required – Red Blood Cells
PSBC REQUISITION

Sample in last 3 days
Must Match

Must Match 
(label at bedside
immediately after draw,
sign, add date/time)
 Not required – platelets, plasma, or cryo

If pt’s blood type (ABO/Rh) on file at the Puget
Sound Blood Center
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2nd Confirmatory ABO/Rh Sample (PSBC)
 If patient has no prior history of a blood type (ABO/Rh)
at PSBC, a 2nd separately collected sample is required
before routine RBCs will be issued
 Purpose – Increased Safety!


Double check blood type
Prevent WBIT errors – which can be fatal
 Must be drawn at different time than 1st sample
2 Person BEDSIDE CHECK
•
•
•
•
•
•
•
•
Informed Consent
Check component against MD’s order
Involve patient, ask patient to state name and birth date, verify against
armband
Compare items shown below, must be identical
Compare patient’s blood type on trans report with unit type to ensure
they are compatible
Check compatibility testing date/time, if performed
Visual Inspection
Check boxes - sign tag
Trans Tag
 1st sample
Name
MRN
 2nd sample
Transfusion Report
(tag attached to blood bag)
Blood Bag Label
Name
MRN
Unit #
Blood Type
Expiration
Unit #
Blood Type
Expiration
Importance of
2 Person BEDSIDE Check
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Transfusion Rates – Routine Non-Emergent
(Adults)
Monitoring - Recommendations
1. Start transfusion within 30 min of Lab issue

If cannot, return within 30 min
2. Transfusion Assessment (Vital Signs, SaO2, lung
and skin assessments)
 First 15 minutes (non-emergent):
 Start slowly


Pre, 15 min, End
 1 hr post
 Any time reaction is suspected
Adults = 100 ml/hr
Always give slow 15 minute test dose

3. Stay with patient - first 15 min
 After 15 minutes:
 If no reaction, increase to rate on Transfuse Order

Rate guidelines for non-emergent transfusions:
4. Reaction Assessment q 30 min

5. Complete within 4 hrs of issue from Lab or before



expiration (if sooner)
Red cells: 1.5 - 4 hr
Platelets:
1 hr
Plasma: 30 - 60 min
Cryo:
15 - 30 min
Acute Transfusion Reactions
Transfusion Reactions – Signs/Symptoms
Stop and do not restart:
Anxiety
Hypotension/Shock
Hypertension
Fever (>1 oC or 1.8 oF)
Chills (with or without fever)
Pain - Back, Chest, IV
Dyspnea
Tachycardia
Hemoglobinuria
Oliguria / Anuria
Hives
Itching
Cough
Nausea
Vomiting
Abdominal cramps
Headache
Cyanosis
Diaphoresis
Generalized bleeding
 Febrile Nonhemolytic
 Acute Hemolytic
 Transfusion Related Acute Lung Injury
 Anaphylactic
 Bacterial Contamination
 Volume Overload
With Provider order, may restart:
 Urticarial (Mild Allergic)
Stop
Antihistamine (Benadryl)
 If reaction resolve, restart slowly
 Observe q 15 min


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Possible Reaction - Steps
1)
STOP TRANSFUSION
2)
Notify Provider (RRT/Code prn)
3)
Monitor vital signs and symptoms
4)
Check tag against armband and bag label to
Reaction Workup – Submit to Hospital Lab
Bag and attached
tubing/IV solution
verify right unit was given to right patient
5)
1 or 2 Lavender or pink tops
Hang new IV set with new 0.9% NS bag to keep
line open (TKO). Do not flush or use blood set.
6)
Treat symptoms per Provider’s orders
7)
Send workup to hospital lab
Call Lab to obtain pink PSBC Reaction form
Next Fresh Urine
Sample (if red/dark)
Conclusion
Reference Information
 Nurse plays a key role in administration of a safe and
effective transfusion




Special Attributes Indications Sheet
ABO/Rh Compatibility Chart
Transfusion Reaction Algorithm
Other guides at psbc.org
 Keep patient safe by understanding/following safe
practices:
Blood Component Indications
Special Processing Attributes Indications
 Type and Crossmatch process
 Pre-Transfusion Beside Check
 Transfusion Reactions


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Resources
 Institution’s Policies and Procedures
 Puget Sound Blood Center’s Website
 http://www.psbc.org
 Transfusion Safety Officer, Mary Grabowski
Pager 206-969-5222 or marygr@psbc.org
 Puget Sound Blood Center Lab (206) 292-6525, #3
 Request On-Call Physician as needed
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