THE INSIDE STORY OF
BLOOD TRANSFUSION
DR.MOHAMED BILAL DELVI
ASSISTANT PROFESSOR
DEPT OF ANAESTHESIA
COLLEGE OF MEDICINE
KSU.
Done by : 428
surgery
team
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team
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What is blood?
 A highly specialised circulating tissue which
has several types of cells suspended in a
liquid medium called plasma.
 Origins from Greek ‘haima’
 Blood is a life sustaining fluid
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 Blood is an amazing fluid!
 Keeps us warm
 Provides nutrients for cells, tissues and
organs
 Removes waste products from various sites
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Blood Composition
 Plasma: 55%. (50% water + 5% plasma
substance)
 Formed elements: 45%.
 - RBC: live in circulation for 120 days. (near
45%)
 - WBC: their life in circulation extends from
months to years.
 - Platelets: their life in circulation is 6-10 days.
WBC + platelets less than 1%
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Blood components
 Blood Products:
 Whole Blood
 Packed red cells RBC.
 Platelets concentrate.
 White cell concentrate.
 Plasma Products:
 Fresh Frozen Plasma FFP.
 Frozen plasma
 Cryoprecipitate.
 Albumin containing solution.
 Human Immunoglobulins.
 Prothrombin complex concentrate.
 Factor VIII concentrates.
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Whole Blood
Centrifugation
Platelet – rich
Plasma
Red Cell
Concentrate
Centrifugation
Platele – poor
Plasma
Platelet
Concentration
Freezing
- 30° C
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Fresh Frozen
Plasma (FFP)
Cryoprecipitation
4° C
Supernatant
Precipitate
(cryoprecipitate)
Supernatant
Prothrombin
Complex
Concentrate
Immunoglobulins
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Precipitate
(fibrinogen)
Factor VIII
Concentrate
Plasma Protein Fraction
(PPF)
Albumin
7
Packed Red Blood Cells
 One unit contains 300 ml.
 Out of this, 70% are RBC.
 Indicated in:
 - Acute blood loss,
 - Chronic anemias.
 Shelf life 42 days at 4 C
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Platelet Concentrate
 One unit contains 50 x 109 platelets.
 Usually 5-6 units are given as one pool.
 Indicated in:
 - Bleeding due to platelet deficiency.
 - Bleeding due to platelet dysfunction.
 Shelf life 5 day at 22 C
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WBC Concentrate
 Difficult to get sufficient quantities.
 Half life is only 8 hours.
 Rarely indicated because most patients
respond to antibiotics and do not need white
blood cells.
 Nonhemolytic transfusion reactions are
common.
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Plasma Products
 1. Fresh frozen plasma (FFP):
 Stored at – 30° C.
 Shelf life 1 year.
 Rich in all components of plasma.
 Indicated in:
 - Disseminated intravascular coagulation
(DIC).
 - Liver failure.
 - Warfarin overdose.
 - Massive RBC transfusions.
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2- Cryoprecipitate
 Prepared from FFP after thawing it to 4° C.
 When refrozen, the shelf life is 3 to 6 months.
 Rich in factors VIII, XII, XIII and VWF (Von
Willebrand factor).
 3- Factor VIII concentrate:
 Prepared by fractionation of cryoprecipitate.
 Large numbers of cryoprecipitate are
required.
 Indicated in hemophilia. Type A
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4- prothrombin complex concentrate:
 Contains factors II, VII, IX, and X.
 Indicated in hemophilia B.
 5- Human immunoglobulins:
 Nonspecific immunoglobulins are used in:










- Congenital immunodeficiencies.
- Acquired immunodeficiencies.
- Idiopathic thrombocytopenia purpura (ITP).
Specific immunoglobulins are used in:
- Hepatitis B.
- Herpes zoster.
- Rubella.
- Rabies.
- Tetanus.
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- Measles.
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6- Albumin containing solutions:
 Used as plasma expander in severe
hemorrhage while waiting for blood.
 Also used to maintain plasma albumin levels
in:
 - Liver failure.
 - Malnutrition.
 - Protein losing states.
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Blood Types:
 O Rh-positive
 O Rh-negative
 A Rh-positive
 A Rh-negative
 B Rh-positive
 B Rh-negative
 AB Rh-positive
 AB Rh-negative
38%
7% universal donor
34%
6%
9%
2%
3% universal recipient
1%
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INDICATIONS FOR BLOOD
TRANSFUSION
 Massive blood loss – acute blood loss.
 Different types of anaemia – chronic anemias.
 Haemophilia & other clotting factor
deficiency – chronic deficiency of any blood
component.
 Cancer patients
 For surgeries
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HISTORICAL ASPECTS
* 15th century- unsuccessful attempts.
 1666- dog to dog transfusion ( ‫بعض الشباب قالوا جا عليها‬
 ‫)سؤال‬
 1667-animal to human
 1818- human to human
 1901- major breakthrough- discovery of
A,B,O groups.
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HISTORICAL ASPECTS
 1907- cross matching
 1914- anticoagulant discovered
 1936- first blood bank
 1939/40- Rh factor discovery
 1950- plastic blood containers.
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DOG TO DOG TRANSFUSION
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SHEEP TO HUMAN TRANSFUSION
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HUMAN TO HUMAN TRANSFUSION
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Theoretical Yield of components
 1 unit of blood theoretically gives



1 unit FFP
1 unit PRBC’s
1 single donor unit cryoprecipitate, single
donor unit platelets

Plasma for Ig and albumin
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BLOOD GROUP SYSTEMS
 ABO System Most studied & important
 Rh system
from clinical point of view.
 Lewis
 Kell
 Duffy
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BLOOD GROUP SYSTEMS
 MNSs
 Lutheran
 P
 Ii
 kid
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DIFFERENT BLOOD GROUPS
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BLOOD GROUP
ANTIGEN
ANTIBODY
A
A
Anti-B
B
B
Anti-A
A,B
None
H
Anti-A,
Anti-B
AB
O
Bombay Group
None
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Anti-A,
Anti-B,&
Anti-H
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RHESUS MONKEYS
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BLOOD DONATION CRITERIA
 Good general condition.
 Age: 18 to 60 years.
 Weight- >45kg for 350ml,
>55kg for 450ml.
 BP: syst. 100-180mmHg
diast. 50-100mmHg.
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 Pulse: 60 to 100beats/min.
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BLOOD DONATION CRITERIA
 Temp. >37.5deg.C
 Hb. >12.5gm%
 Jaundice
 Malaria
 High risk behaviour
 Pregnancy
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BLOOD DONATION CRITERIA
 Surgeries
 Last blood donation
 Tattooing
 Chronic diseases
 Last blood transfusion
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INSTRUCTIONS TO DONOR
AFTER DONATION
 More fluids than usual.
 Do not remain hungry.
 Do not smoke for 1hour.
 Remove bandage after 6 hours.
 If bleeding from puncture site, apply pressure.
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 If feeling faint/dizzy, lie428down.
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MISCONCEPTIONS/ REASONS FOR
NOT DONATING BLOOD
 Fear of contracting some disease
 I do not have enough blood/ I will become weak.
 I am too old
 I am too busy.
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REASONS TO DONATE BLOOD
 New blood formation .
 Regular health check up.
 Blood investigations done.
 Satisfaction of noble work.
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TESTS DONE IN BLOOD BANK
 Blood grouping & Rh typing
 Cross matching
 Tests for irregular antibodies
 HBsAg test & Anti-HBc
 HCV test
 HIV test (HIV1 & HIV2)
 Test for syphilis
 Test for malaria
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Cells v Serum
Serum v Cells
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Cell
Grouping
Serum Grouping
Interpretation
Anti
A
Anti
B
Anti
AB
A cells
+
-
+
-
+
-
A
-
+
+
+
-
-
B
+
+
+
-
-
-
AB
-
-
-
+
+
-
O
-
-
-
+
+
+
Bombay Blood
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Group
B cells O cells
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BLOOD
GROUP
ANTIGEN
ANTIBODY
Can give
blood to
Can receive
blood from
A
A
Anti-B
A,AB
A,O
B
B
Anti-A
B,AB
B,O
A,B
None
AB
H
Anti-A,
Anti-B
AB
O
Bombay
Group
None
Anti-A,
Anti-B,&
Anti-H
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A,B,AB
Bombay
group (Oh)
A,B,AB,O
O
Bombay
group (Oh)
41
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Screening tests on donors’ blood:
- Hepatitis B surface antigen (HBsAg).
- Hepatitis B core antibody (anti-HBc).
- Hepatitis C virus antibody (anti-HCV).
- HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2).
- HTLV-I and HTLV-II antibody (anti-HTLV-I and antiHTLV-II).
-Serologic test for syphilis.
Prerequisites:
-Take samples for full blood count (FBC), serum iron or
ferritin B, and folate levels.
- Cross match.
- Choose the appropriate blood group in emergency.
- Appropriate IV access.
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MISMATCHED TRANSFUSION
Group A
+
Group B = Clumping of RBCs
+
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AUTOLOGOUS DONATION
 Self help is the best help.
 Planned gynaecological, orthopedic, plastic
general surgeries
 Individuals with rare blood groups/ irregular
antibodies/ infectious disease positive.
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AUTOLOGOUS DONATION
Advantages
 Safest blood.
 Easy availability
 No risk of TTDs
 Best option in patients with irregular antibodies,
rare blood groups, infectious disease positive.
 Blood scarcity can be reduced to some extent.
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Blood Transfusion:
A. Autologous:
-
Blood donor and transfusion recipient are the same in order to
avoid blood borne diseases or infections.
Four types:
1. Preoperative donations:
- Donating the patient’s own blood before surgery.
- The blood bank draws the patient’s blood and stores it until
he/she needs it during or after surgery.
- Only for elective surgery.
2. Preoperative hemodilution:
- Immediately before surgery, some of the patient’s blood is
taken and replace with IV fluids, i.e. normal saline.
- Only for elective surgeries.
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3. Perioperative (intraoperative) collection:
- Recycling the patient’s blood during surgery.
- Blood lost during surgery is filtered, and put back into the
patient’s body during surgery.
- Can be done in emergency and elective surgeries.
4. Postoperative collection:
- Recycling the patient’s blood after surgery.
- Blood lost after surgery is collected, filtered and returned
to the patient’s body.
- Can be done in emergency and elective surgeries.
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B. Allogenic:
Blood transfused to someone other than the donor.
Practical tips:
Give one unit over 4 hours.
Use blood warmer if patient is hypothermic.
Give 40 mg IV frusemide in between each unit.
If possible, give transfusions early in the day.
Check hemoglobin 24-48 hours after transfusion.
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Complications of Transfusion:
Transfusion reaction.
Transmission of infections.
Hyperkalemia.
Hypocalcemia.
Thrombocytopenia.
Depletion of clotting factors.
Transfusion reaction:
Fever.
Urticarial rash.
Agitation.
Chest or abdominal pain.
Hypotension.
Wheezing.
Severe back pain.
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Management of transfusion reaction:
Stop transfusion.
Return the remaining blood to lab.
Give 100 mg of hydrocortisone and 10 mg chlorpheniramine IV.
Recheck the cross matches.
Monitor vital signs.
Monitor urine output.
Inform your senior colleague.
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Compatibility chart for elective transfusion (for your knowledge)
Recipient’s blood group
Donor’s blood group
A+
B+
AB+
O+
A-
B-
AB-
O-
A+
+
-
-
+
+
-
-
+
B+
-
+
-
+
-
+
-
+
AB+
+
+
+
+
+
+
+
+
O+
-
-
-
+
-
-
-
+
A-
-
-
-
-
+
-
-
+
B-
-
-
-
-
-
+
-
+
ABO-
-
-
-
-
+
-
+
-
+
-
+
+
In emergencies, the Rh – person can receive few units of Rh + blood if he/she has no anti-D antibodies.
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They are generally elderly male patients.
BLOOD COMPONENTS
 Blood separated into different parts.
1) Packed red cells
2) Platelets
3) Fresh frozen plasma
4) Cryoprecipitate
5) Granulocytes
6) Factor IX conc.
7) Factor VIII conc.
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COMPONENTS
Advantages
 Overload avoided.
 Better patient management.
 Greater shelf life than whole blood.
 Blood shortage can be overcome.
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COMPONENT SEPARATION
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COMPONENT SEPARATION
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FINAL PRODUCTS
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Blood component
Contents
Volume
Shelf life
Whole blood
Hct.35%,RBCs,
WBCs.450ml blood,63ml
CPDA1
520ml
35 days at
4deg.C.
Red cells
Hct.60%,RBCs,25mlplasma,
100 ml Adsol.
340ml
42 days at
4deg.C
Platelets
Platelets,few
WBCs,RBCs,
50ml plasma
50ml
5 days at
22deg.C
FFP
Pl.proteins,clot.
Factors
428VIII,IX.
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Fibrinogen,factor
225ml
1year at
-18deg.C
Cryoppt.
15ml
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APHERESIS
CELL SEPARATOR
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APHERESIS
 Plasmapheresis: plasma is removed.
 Plateletapheresis: platelets are removed.
 Leukapheresis: leucocytes are removed.
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The rational use of blood
and blood products
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BLOOD LOSS- Signs, Symptoms and Indication
for Transfusion
Volume Lost
Clinical signs
mL % of Total
Blood Volume
500
10
None;
1000
20
tachycardia
1500
30
drop in BP
2000
40
shock
Preparation of choice
No transfusion or crystalloid solution
crystalloid solution or colloids or RBC if
necesssary
crystalloid solution plus colloids plus
RBC or blood if available
crystalloid solution plus colloids plus
RBC or blood if available
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RED CELLS TRANFUSION-Indication(1)
1. Whole blood
• acute hypovolemia (hemorrhagic
shock)
• massive transfusion
• exchange transfusion in infants for
hemolytic anemia of the newborn
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Packed red cells
 150-200 mls. of red cells with plasma
removed
 Haemoglobin 20g/ 100 ml, PCV 55-75
 Expected rise in Hb with 1 unit of red cells is
approximately 1g/dL
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Indications for Packed Cells
 Massive blood loss
 Anaemia of chronic disease
 Haemoglobinopathies
 Perioperative period to maintain Hb> 7g/dL
 No need for transfusion with Hb >10
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Platelets
 150-400 x109 /L
 Platelet units can be either


Single donor units
Apheresis units
 1 single donor unit contains 55 x109
 1 apheresis unit contains 240x109
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Platelets
 Stored at room temperature
 Constantly agitated
 Only last for 5 days
 1 dose of platelets should raise patient’s
counts by 30 x109 after 1 hour
 Infused in 15 mins
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Indications for platelet transfusion
 BLEEDING due to thrombocytopaenia
 Due to platelet dysfunction
 Prevention of spontaneous bleeding with
counts < 20
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Recommended counts to avoid bleeding
Platelet
count /ul
Clinical Condition
> 100 000
Major abdominal, chest or neurosurgery
> 50 000
Trauma, major surgery
> 30 000
Minor surgical procedures
> 20 000
Prevention/treatment of bleeding in pts
with sepsis, leukemia, malignancy
> 10 000
Uncomplicated malignancy, leukemia
>
5 000
ITP patients at low risk
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FFP
 Fresh Frozen Plasma
 Plasma collected from single donor units or
by apheresis
 Frozen within 8 hours of collection
 -18o to -30o C
 Can last for a year
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FFP
 1 unit is 250 ml
 Contains all plasma proteins
 Indications:




Correction of bleeding due to excess warfarin,
Vitamin K deficiency, liver disease
DIC, dilutional coagulopathy
Inherited factor XI deficiency
TTP
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FFP
 Dose: 15 mls/kg about 3-5 units
 FFP and INR <2
 Give at 1ml/kg per hour in likely fluid overload
patients
 Given within 24 hours of thawing
 Requesting FFP
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Frozen Plasma
 Plasma frozen within 24 hours of collection
 Maintains level of plasma proteins except
factor VIII
 Same indications as FFP
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Cryoprecipitate
 FFP thawed at 4oC and centrifuged
 Cryoprecipitate is the by-product
 Contains Fibrinogen, Factor VIII, Factor XIII,
von Willebrand’s Factor
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Cryoprecipitate
 No longer indicated for Hemophilia*
 Source of Fibrinogen in acquired
coagulopathies as in DIC; platelet
dysfunction in uremia
 Indicated for bleeding in vWD, Factor XIII
deficiency
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Cryoprecipitate
 Infused as quickly as possible
 Give within 6 hours of thawing
 10-15 mls; usually 10 units pooled
 10 bags contain approx. 2gm of fibrinogen
and should raise fibrinogen level to 70mg/dL
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Almost there!!!!!!!
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Appropriateness of transfusion
 May be life-saving
 May have acute or delayed complications
 Puts patient at risk unnecessarily
 ‘ The transfusion of safe blood products to
treat any condition leading to significant
morbidity or mortality, that cannot be
managed by any other means’.
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Inappropriateness of transfusion
 Giving blood products for conditions that can
otherwise be treated e.g. anaemia
 Using blood products when other fluids work
just as well
 Blood is often unnecessarily given to raise a
patient’s haemoglobin level before
surgery or to allow earlier discharge from
hospital. These are rarely valid reasons for
transfusion.
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Inappropriateness of Transfusion
 Patients’ transfusion requirements can often
be minimized by good anaesthetic and
surgical management.
 Blood not needed exposes patient
unnecessarily
 Blood is an expensive, scarce resource.
Unnecessary transfusions may cause a
shortage of blood products for patients in real
need.
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Problems faced
 Too few donors
 Lack of equipment
 Insufficient products
 Insufficient reagent
 Infectious disease testing
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Recommendations
 Increase public awareness about need for blood and
hence the number of voluntary donors
 Continue to encourage relatives to donate for
patients*
 Increase the number of mobile clinics
 Extend the opening hours for blood collecting
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Recommendations
 Management of stocks of blood and blood products
 Maintenance and replacement of equipment
 On-going training of Haematology Lab Staff
 Better management of reagents for- infectious
disease testing, antigens etc.
 Improved record keeping
 Move to electronic record keeping
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Recommendations
 View to reduce the need for allogeneic
transfusions
 Autologous transfusions
 Blood saving devices in OR (operating room)
 Acute normovolemic haemodilution
 Oxygen carrying compounds
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Bibliography
 Uptodate.com
 British Transfusion guidelines 2007
 Clinical use of blood, WHO
 MJA: Tuckfield et al.,Reduction of inappropriate use of blood products






by prospective monitoring of blood forms
Transfusion practice: Palo et al., Population based audit of fresh frozen
plasma transfusion practices
Vox Sanguinis: Titlestead et al., Monitoring transfusion practices at two
university hospitals
Transfusion: Schramm et al., Influencing blood usage in Germany
Transfusion: Healy et al., Effect of Fresh Frozen Plasma on
Prothrombin Time in patients with mild coagulation abnormalities
Transfusion: Sullivan et al., Blood collection and transfusion in the USA
in 2001
Transfusion: Triulzi, The art of plasma transfusion therapy
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