Blood 101

Hank Hanna, MDMedical Director

American Red CrossPacific Northwest

ObjectivesBecome familiar with the Donation Process

Understand the components of whole blood and how they are processed and modified.

Understand testing on donor units.

Know the indications for RBC, Plasma, Cryoprecipitate and Platelet Transfusion.

Recognize various types of transfusion reactions.

Become aware of alternatives to transfusions.

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BackgroundEvery two seconds, someone in the US needs a blood transfusion.

Across the nation, the Red Cross collects approximately 5.3 million pints of blood from 3.1 million volunteer donors annually.

These blood donations are then processed into >7.7 million blood products.

Regionally we collect 250,000 pints of blood each year.

We serve 60 hospitals in OR and WA

Regulated by: FDA, AABB, CMS(CLIA), FACT

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Donation Process

Health History QuestionnairePhysical

Ways to Donate

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Donation ProcessScreening – required by FDA in order to maintain a safe blood supply.

• Behavioral

• Physical

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Health History QuestionnaireAddresses behavioral part of screening

• Most blood facilities use a Health History Questionnaire

• All allogenenic donors must answer these questions.

• Sexual Behavior

• IV Drug Use

• Travel History

• Living Conditions

• Medications – Rx and OTC

• Current Health State

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PhysicalVital Signs• Heart Rate – 50-100 bpm• Temp - ≤37.5ºC per FDA• Blood Pressure – 180/100• Hemoglobin - ≥12.5 g/dL per FDA

• 12.0 g/dL for women is under consideration

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Ways to Donate• Whole Blood

• RBC, plasma, cryo• Time: approx. 5 min.• Donation Interval: every 8 weeks

• Apheresis• Double RBC, plasma, platelets, cryo• Time: approx. 45-90 min. depending on product• Donation Interval

• Double RBC 16 weeks• Plasma every 4 weeks• Platelets every 2 days but no more than 2x/7 days and 24x/year

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Component Processing

Whole BloodApheresis

Component Modification

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Whole Blood Processing• Processed after donation• RBC, plasma and cryoprecipitate• Usually occurs within 8 hours of collection

• Centrifuged to separate red cells from plasma/cryoprecipitate

• Plasma moved into separate bag and then frozen to -18ºC• Plasma thawed to precipitate cryoglobulins, centrifuged and

pushed into satellite bag• Plasma and Cryo stored at -18ºC for 1 year

• RBC’s leukoreduced and then stored at 1-6ºC for 42 days

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Apheresis Processing• Components separated time of collection• Whole blood removed from vein into spinning pheresis bag

• Spin creates gradients of RBC, platelets and plasma

• Exit tubes at various levels for each component

• Open the exit tube for desired component, drains to collection bag

• Rest is returned to donor• Double arm and single arm

• Platelets stored at RT for 5 days

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Component Modification - Leukoreduction

• RBC are allowed to pass through WBC reducing filter (<5.0x106 WBC)

• Performed to reduce CMV transmission• Febrile transfusion reactions and HLA

alloimmunization.

• Seronegative CMV vs Leukoreduction

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Component Modification - Irradiation

• Inactivates lymphocytes to prevent TA-GVHD• RBCs are exposed to gamma or x-irradiation• Changes expiration of RBC to 28 days.

• Indications• IUT, infants who have received IUT• Cellular immunodeficiency• Neonatal exchange transfusions• Granulocyte transfusion• Components from blood relatives

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Donor Unit Testing

DiseaseSerologic

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Disease Testing• Prevents disease transmission

• Hepatitis B• Hepatitis C• HIV-1,-2• HTLV I/II• Syphilis• WNV• Chagas• Bacteria (platelets only)

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Serologic Testing• ABO• D Antigen(Rh)• Weak D Antigen• Antibody Screen

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Transfusion

Recipient TestingRBC

PlasmaCryoprecipitate

Platelets

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Recipient Testing• Type and Screen• ABO• D Antigen• Weak D Antigen• Antibody Screen • Must have a sensitizing event (previous transfusion or

pregnancy) and be negative for those specific antigens• Rh, Kell most common

• Donor compatibility (Crossmatch)• Donor RBCs • Platelets

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Blood Group Compatibility

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Blood Group Compatibility

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Blood Types and the Population

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  Caucasians African American

Hispanic Asian

O + 37% 47% 53% 39%

O - 8% 4% 4% 1%

A + 33% 24% 29% 27%

A - 7% 2% 2% 0.5%

B + 9% 18% 9% 25%

B - 2% 1% 1% 0.4%

AB + 3% 4% 2% 7%

AB - 1% 0.3% 0.2% 0.1%

RBC• Indications

• Symptomatic Anemia• Red Cell Exchange• Exchange Transfusion

• No "Magic Number"

• Contraindications• Anemia that can be corrected with a non-transfusion therapy.• Increasing blood volume• To improve wound healing

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Plasma• Indications

• Active bleeding or risk of bleeding due to deficiency of multiple coagulation factors or a single factor for which no concentrate is available.

• Severe bleeding due to warfarin or urgent reversal of warfarin effect.• Massive transfusion• TTP

• Contraindications• Increasing blood volume or albumin concentration.• Coagulopathy that can be corrected with Vitamin K.• Normalizing abnormal coagulation results in the absence of bleeding.

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Cryoprecipitate• Indications

• Source of fibrinogen• Massive transfusion• Plasmapheresis

• Contraindications• Do not use for specific factor deficiencies for which a concentrate is

available.

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Platelets• Indications

• Bleeding due to decreased or functionally abnormal platelets.

• Prophylactic:  • >10,000/mL in stable, non-bleeding patients• >20,000/mL in unstable, non-bleeding patients• >50,000 in actively bleeding patients or patients undergoing invasive

procedures/surgery

• Contraindications• ITP, TTP, HIT, Thrombosis

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Transfusion Reactions

Hemolytic – Acute and DelayedNon-Hemolytic

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Transfusion Reactions• STOP the transfusion• THINK, could it be an AHTR?• TREAT patient• INITIATE transfusion reaction workup

• Types• Hemolytic: Acute, Delayed

• Non-Hemolytic: Febrile, Allergic, Volume Overload (TACO), TRALI,

• Bacterial, TA-GVHD

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Acute Hemolytic Reactions• Symptoms: flank or back pain, hematuria, fever, chills,

nausea, vomiting, dyspnea, hypotension, renal failure, DIC, IV site pain

• Cause: most commonly ABO incompatibility• Pathophysiology: complement-mediated intravascular

hemolysis• Potentially Fatal• Treatment: discontinuation of transfusion, hydration,

intensive patient monitoring

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Delayed Hemolytic Reactions• Symptoms: Less severe than AHTRs, fever and chills hours

to days after transfusion• Cause: immunologic incompatibility not identifiable at time

of recipient testing• Pathophysiology: RBCs tagged for removal by splenic

macrophages• Treatment: supportive

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Non-Hemolytic Febrile

• Symptoms: fever (↑1ºC), chills, malaise• Occurrence: 1% of all transfusions• Pathophysiology: cytokine release • Treatment: stop transfusion, evaluate for hemolysis

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Non-Hemolytic Allergic

• Symptoms: urticaria• Occurrence: About 3% of all transfusions• Pathophysiology: recipient antibodies against donor plasma

proteins• Treatment: antihistamines, may continue transfusion after

resolution of symptoms

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Non-Hemolytic Volume Overload (TACO)

• Symptoms: dyspnea, cough, hypertension, tachycardia• Occurrence: <1% of transfusions. More common in elderly,

pre-existing cardiovascular disease• Pathophysiology: inability of circulation to handle

transfused fluid volume• Treatment: oxygen, diuretics, supportive care

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Transfusion Associated Lung Injury(TRALI)

• Symptoms: hypoxemia, respiratory failure, hypotension, fever, noncardiogenic pulmonary edema, • Symptoms arise within 6 hours of transfusion

• Occurrence: 1 in 5,000 transfusions• Pathophysiology: likely caused by donor antibodies to

recipient WBC, WBC’s activated by other donor substances

• Treatment: supportive care(O2, ventilation), hemodynamic stabilization

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Non-Hemolytic Bacterial/Sepsis

• Symptoms: severe chills, fever, hypotension, nausea, vomiting

• Occurrence: rare due to bacterial testing prior to distribution• Pathophysiology: endotoxin release• Treatment: stop transfusion, culture patient

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Graft-Versus-Host Disease(TA-GVHD)

• Symptoms: fever, rash, enterocolitis, elevated liver function tests, pancytopenia

• Occurrence: rare but almost uniformly fatal• Pathophysiology: donor lymphocytes mount attack against

recipient• Prevention: irradiation

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Transfusion Alternatives

Hemoglobin SubstitutesPerfluorocarbon Emulsions

Intravenous Iron (“Bloodless Surgery”)

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Hemoglobin Substitute• Mainly consist of free hemoglobin that is unstable and toxic

with short half lives due to phagocytosis and RES uptake.• Ideal Substitutes:

• Free of toxicity and side effects

• Able to uptake O2 in the lungs and deliver O2 to tissues

• Sufficient half life

• Rapid and harmless excretion

• Stable at room temperature, easy to store

• Easy to sterilize

• Cheap to manufacture

• No need for compatibility testing

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Perfluorocarbon Emulsions• Hydrocarbons with Hs mostly replaced by Fs

• Dissolve O2 instead of binding like hemoglobin• Have some utility and show more promise than hemoglobin

substitutes but can cause progressive hypertension at higher doses, patients may be more predisposed to stroke.

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Intravenous Iron• “Bloodless Surgery”• Administer Iron and Erythropoietin for several days prior to

surgery to stimulate hematopoiesis

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Day Dose

1 1-2 g IV Iron

2 Erythropoietin, Vit B12

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4 Erythropoietin, Vit B12

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6 Erythropoietin, Vit B12

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8 Erythropoietin, Vit B12

9 Erythropoietin, Vit B12

10 Erythropoietin, Vit B12

Surgery

Discussion / Questions?

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