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• The blood components are red cell concentrates, platelet concentrates, fresh plasma & cryoprecipitate & plasma derivatives (albumin, coagulation factors & immunoglobulins).

PRBC

• Packed Red Blood Cells are prepared by centrifugation of whole blood to remove approximately 80 % of the plasma.

• Preservative solution like citrate phosphate dextrose with additional nutrients adenosine, glucose and mannitol is added.

• Each unit of PRBC has a hematocrit of 55 – 80% and a volume of approx 250ml.

• Transfusion of 1 unit into a typical adult increase the hematocrit by 3% and hemoglobin by 1 gm/dl.

• PRBCs may be further treated to meet specific uses : Leukocyte reduced PRBCs, irradiated PRBCs, washed PRBCs and frozen PRBCS.

• Leukocyte reduced PRBC

  • 70 - 85% of the leuckocyte are removed.

  • Advantage:

1. To avoid non hemolytic febrile reactions due to antibodies to white blood. cells if the patient has been exposed to previous transfusions or pregnancies.

2. To prevent sensitization in patients who may be eligible for bone marrow transplantation.

3. To minimize the risk of virus transmission such as human deficiency virus and cytomegalovirus.

• Irradiated PRBC

  • Irradiating the PRBC eliminates the capacity of T-lymphocytes to proliferate, thereby preventing the donor's T-lymphocytes from reacting to the recipient's cell and causing graft versus host disease. They are considered in transplant patients, neonates, immunocompromised patients.

• Washed PRBC

  • They are indicated in patients who have a hypersensitivity to plasma, such as immunoglobulin A deficiency.

PLATELET

• Platelet transfusion is usually type specific , but depending on availability non type specific platelets may sometimes be transfused.

• This transfusion is better to be avoided in children's or patients receiving multiple transfusions because they are at a higher risk of complications.

• Transfusing platelets that are not type specific may also shorten the half life of transfused platelets.

FFP

CRYOPRECIPITATE

• It was the first method for preparing a more concentrated form of antihemophiliac factor.

• It prepared by thawing FFP to precipitate high molecular weight proteins including factor VIIIc, von wilebrand factor & fibrinogen.

• The cryoprecipitate from single donor contains 80 – 300 units of factor VIII & von willebrand factor & 300 -600 mg of fibrinogen in 20 -50ml.

• DOSE : 10 single unit (I unit per 5kg)containing 3-6gm fibrinogen in a volume of 200 -500ml it would typically rise fibrinogen levels by 1gm/L.

Infusion rate & duration for blood components

PRBC

• Rapid infusion may be required in managing a major hemorrhage a unit over 5-10min.

• In elderly slow infusion rate is recommended.

• A unit can be safely administered over 3hrs , but not more than 4hrs.

PLATELETS

• They have short half life and has to be infused within 30-60 min per pack.

FRESH FROZEN PLASMA

• Rapid infusion can be given to replace coagulation factors. Acute reactions are common with faster rate of transfer.

ADMINISTRATION

• Standard IV cannula is preferred for blood transfusion.

• All blood components can be slowly infused through small bore cannula or butterfly needles.

• PRBC must be adminstrated via a sterile blood administration set with an intergral screen filter (170 – 200 μm).

• The infusion line should be changed every 12hrs.

• Platelet & plasma component may be administrated by a normal blood administration set or via platelet/cryoprecipitate administration set.

• Platelets should not be administrated through an set used for PRBC transfusion as it may cause aggregation & retention of platelets in the line.

ADVERSE REACTION

Acute Hemolytic Reaction

• Immediate transfusion reactions are caused by ABO incompatibility.

• Incompatible transfused blood cells react with the patients own anti -A or anti -B antibodies and cause severe clinical reaction.

• It is most severe when a group O patient receive group A red cells.

• Risk of hemolytic reaction due to incompatible blood is 1 – 4 per million units transfused and has a high case fatality rates.

• In acute hemolytic reaction, the transfused cells are destroyed which may result in activation of the coagulation system with DIC and release of anaphylotoxins and other vasoactive amines.

• Patient may have bleeding, tachycardia, hypotension or hypertension.

• Patients may also have fever, bronchospasm, can develop pulmonary edema.

• Acute hemolysis may also occur following infusion of plasma rich components usually platelets or FFP, containing high titre anti red cell antibodies usually anti A or b.

• In intravascular hemolysis serum haptoglobin will be decreased, serum LDH will be elevated, Direct Coombs wil be positive.

• Management :

  • Stop transfusion,

  • Crystalloid resuscitation , inotrope support.

  • Blood culture, sample from blood component pack, inform blood bank

  • Hematology consultation.

Anaphylaxis

• Rare but life threatening complication occurring during early part of transfusion.

• Signs : hypotension, bronchospasm, periorbital or laryngeal oedema, vomiting, erythema, utricaria, conjuntivitis .

• Symptoms: dyspnea, abdominal pain, nausea, chest pain.

• Less severe allergic reaction : Utricaria / itching within minutes of starting transfusion are quite common.

• Management

  • Transfusion may be continued if there is no progression of symptoms after 30min.

  • Chlorpheniramine should be given before transfusion if patient has previously experienced allergic reaction.

Febrile Non Hemolytic Reaction

• Fever or rigors during red cell or platelet transfusion affect 1-2% of recipients mainly multiple transfusions or previously pregnant patients.

• Presents with fever with shivering.

• Management

  • Slowing or stopping the transfusion.

  • Antipyretics

  • Watch for anaphylaxis.

Transfusion associated circulatory overload (TACO)

• TACO is defined as acute respiratory distress with pulmonary edema, tachycardia, increased blood pressure and evidence of positive fluid balance after a blood transfusion.

Transfusion Related Acute Lung Injury (TRALI)

• It is usually a complication of FFP or platelet transfusion.

• Typically presents as acute onset of breathlessness & cough within 6hrs of onset.

• X-ray : Bilateral nodular infiltrates in batwing pattern, resembling ARDS.

• Loss of circulatory volume & hypotension is common.

• Monocytopenia or neutropenia may be seen.

• It is found that plasma of one of the donors contain antibodies that react strongly with patients leucocytes.

• Management :

  • NIV/ Mechanical Ventilation

  • Diuretics should not be used

  • Steroids are of uncertain benefit.

Infusion Of Blood Pack Contaminated By Bacteria

• Bacterial contamination is rare , it more seen with platelet transfusion .

• Presents with severe acute reaction : Hyper or hypotension , rigors & collapse.

• Examine the pack for discoloration, smell & gram stain.

• Management :

  • Antibiotics

  • Organisms usually isolated are Staphylococcus epidermidis, staphylococcus aeurus, bacillus cerus, group B streptococci, E.coli, pseudomonas.

Delayed Hemolytic Transfusion Reaction

• DHTR is a hemolytic reaction occurring more than 24hrs after transfusion, in a patient who has been immunized by red cell antigen by previous transfusion or pregnancy.

• Antibody are undetectable by routine blood bank investigations. Antibodies of Kidd & Rh system are most frequently involved.

• Features include falling Hb concentration, unexpectedly small rise in Hb, jaundice, fever & haemoglobinuria or renal failure.

• Management : Is conservative, monitor RFT. Send Hb level, LDH, direct antiglobulin test, s. bilirubin, haptoglobin & urine analysis for haemoglobinuria or renal failure.

Transfusion Associated Graft Versus Host Disease

• It is a rare but serious complication due to engraftment & proliferation of transfused donor lymphocytes.

• The damaged recipient cells that carry HLA antigen.

• The skin, gut, liver, bone marrow are affected usually 1 -2 wks following transfusion.

• Presents with fever, skin rash, diarrhea & hepatitis.

Infections Transmissible

• Every donation is tested for hepatitis B surface antigen, hepatitis C antibody and RNA, HIV antibody, HTLV antibody, and syphilis antibody. Tests for antibodies to malaria, T. cruzi and for West Nile virus RNA may be used when travel may have exposed a donor to risk of these infections.

• At present even though blood banks screen the blood sample for these infections, it is impossible to exclude the possibility that some new or currently unrecognized transfusion transmissible infection may emerge. Hence it is better to avoid non essential transfusion.

Updated on 14/1/2015

Reference :

• Handbook of transfusion medicine by DBL Mcclelland

• Gudelines on the management of anemia and red cell transfusion in adult critically ill patients. BJH guidelines 2013.

• Tintinalli