Didi Kurniadhi

Process to transfer blood or blood

components from donor to recepient

Understanding immunology
Understanding complication
Processing secure & effective
Rational indication
Blood donor :
Depend o Hb/Ht; min man 14 gr/dl, woman 13

gr/dl
Ht 6%, min Hb 13 gr/dl, woman 12 gr/dl
Vol (ml) = 1-2 x 6 x kbBB

Donor Interval: 4 mnth

Erythropoesis 120 day

Erytrocyt
e

Serum

Ag

Ab

ABO

None

A&B

A &B

None

AB

Ab Rho

Ag Rho

Rhesus

None

Rh+

None

Rh-

Blood Type

Antibody

Antigen

Blood type

A and B

None

Rho(C,D,E)

None

None

Rho(C,D,E)

Kell (K)

None

Duffy (Fy)

None

hr (c,e)

None

IgG labeled erythrocyte

C3b labeled erythrocyte

Rh Rh+
K Fy hrc,e -

Safety

Rational
Base on indication
Benefit > Risk (Risk & benefit ratio)

Understand & prepare the

complication

Tujuan transfusi:
Replacement
Substitution

Indikasi harus jelas

Klinis sangat penting

Emergency
Supportive
Preventive

risk-benefit

Beri komponen sesuai yang dibutuhkan saja

Sesuaikan dengan keadaan hemodinamik pasien

Emergency:
Massive bleeding

Supportive:
Optimal survival and function

Preventive:
Prevent peri-arthricular destruction

Fresh blood (initially 4h of storage)

Whole blood (more than 4h of storage)

Sel darah merah (RBCs) Packed red cell (PRC)

Washed PRC

Frozen thawed RBCs RBCs miskin Leukocyte

Fresh Frozen Plasma (FFP)/plasma beku segar

Cryoprecipitate (FVIIIc & Fibrinogen)

thrombocyte concentrate (TC)

Component

Storage
period

Storage
temperature

Ht
(%)

Vol./unit
(mL)

Whole blood

21d; 35d

4-6 OC

40

300-450

PRC

21d; 35d

4-6 OC

7080

150-250

28d

4-6 OC

150-200

TC

3d

4-6 OC

25-30

FFP

1y

Below -18 OC

150-200

Cryo

1y

Below -18 OC

10

Liquid
plasma

Diskualifikasi:

Anticoagulant:

Hepatitis, HIV
Parasite (malaria,
etc)
Sakit kanker
Sakit jantung
Asma berat
Epilepsi (convulsions)
Hyper/hypotension
Anemia
Diatesis hemorrhagis

Citrate Phosphate
Dextrose (CPD)
Adenine supplemented
Citrate Phosphate
Dextrose (CPDA-1)
Heparin khusus*)

* Bedah jantung anak, eliminasi sitrat primer, transfusi tukar pada hepatitis fulminan atau
bayi dengan hemolisis berat.

When plasma needed to stabilize

hemodynamic
Emergency:
Massive bleeding: Target to stabilize hemodynamic

Hb >10 g/dl

Estimation deficit:
Vol = Hh x 6 x Body weight (Kg)

Special condition:
No PRC

Red blood cell contain product

:

Packed red cell concentrate

Red cell suspension
Leukocte depleted red cell
Wholle blood
Fresh Wholle blood

Estimation: Vol = Hb x 3 x Kg Body

weight
Emergency high output failure
No need plasma or thrombocyte
Supportive:
Chemotherapy, radiotherapy
Impending high output failure
Low productivity: target optimal Hb

Special condition: washed PRC, leucocyte

Indication:
PNH
Severe hypersensitivity against plasma

Processing 4 hr at 4 6oC
Importance:
Used immedietly in 24 hr after process

hemolysis
Risk Contamination during procces

TC obtain by sentrifugasi/tromboforesis
3 days live
Give as soon as possible infuse set no filter
1 unit TC 10000/uL every 50 kg BW
Dosage = 1 u/10 kg BW

Result:

Influence by number & viability thrombocyte

Poor result fever, infection, + antibody

National institute oh health concensus

confrence on platelet transfusion therapy
(1987):
Profilaxis < 10.000 20.000/uL
Sistemic bleeding or risk of bleeding cause

thrombocytopenia (50.000)

Multiple donor risk antibody

Single donor aferesis

1 bag 6 bag

Fresh Frozen Plasma

Is a plasma containing stable clotting

factor, albumin and immunoglobulin
Factor VIII level at least 70% of
normal fresh frozen plasma
Initial dose 15 ml/kgBW
Should be infused as soon as possible
after thawing (6 hour)

Factor

T in
Vitro

FFP

T postinfusion (h)

Prothrombin

Stable

Stable

60

Fibrinogen

Stable

Stable

96

Vc

3-5 days

Absent

24 (fresh plasma)

VIIc

Stable

Stable

4-6

VIIIv (vWF)

Stable

Stable

6-12

VIIIc

1-2 weeks

Minimal

11-12 (fresh plasma/Cryo)

IXc

Stable

Stable

22

Xc

Stable

Stable

35

XIc

Stable

Stable

60

XIIIc

Stable

Stable

144

AT-III

Stable

Stable

NA

Protein C

Stable

Stable

NA

Protein S

Stable

Stable

NA

 Urgent clinical condition of multifactorial coagulopathy

Vit.K deficient
Warfarin
Severe liver disease

DIC
Correction of microvascular bleeding
PT or aPTT > 1.5 control
Plasmapheresis in plasma exchanges
TTP
Factor replacement
II, VII, X, XI, XIII
AT-III, Protein C, Protein S
FFP = x kgBW/10 mL
Albumin replacement:
Requirement = x kgBW x 25 mL

Single bag 10-15 ml cryo

Constituen Amount per-bag
t

T
postinfusion

VIIIv
VIIIc

100-150 U
80-150 U

12 h
12 h

Fibrinogen
XIIIc

150-250 mg
50-75 U

4-6 d
6-12 d

Is a plasma product contains coagulation

factors.
Must be infused within 6 hours after
thawing
Indication :
As an alternative for factor VIII concentrate in the

treatment of inherited deficiencies of :

Von willebrand factor
Factor VIII
Factor XIII

Replace fibrinogen in acquired coagulopathies (DIC)

Plasma Derivates :

Albumin :
Albumin 5%
Albumin 20%
Albumin 25%

Coagulation Factors
Factor VIII concentrate
Plasma derivates containing factor IX

Albumin :

Preparation :
Albumin 5%
Albumin 20%
Albumin 25%
Stable plasma protein solution and plasma

protein fraction; similar to albumin content 5%

Indication :
Replacement fluid in therapeutic plasma

exchange, albumine 5%
Treatment of diuretic resistant edema, albumin
20% + furosemide

Factor VIII
1 vial contain about 250 iu of factor VIII
Indications :
Treatment of Hemophilia A
Treatment of von willebrands disease: use only
preparation
Preparation and administration :
Once is dissolved draw up the solution and
infuse using infusion set within 1 hours

Plasma derivate containing factor IX :

Prothrombin complex concentrate (PCC)
Factor IX concentrate
Factor II, IX, X

PCC

IX

Factor IX only
Some preparation
contains factor VIII

+
+

Unit of issue : 1 vial contain 360 -600 iu factor IX

Indication : treatment of hemophilia B, corection of
prolonged prothrombin time

Local complication
Failure to achive vena access
Problem in injection area
Poor vena fixation
Rupture vein

General complication
Transfusion reaction
Transmission infection disease
Imunologic sensitization
hemokromatosis

Pyrogenic reaction (fever)

Alergic reaction
Volume overload
Hemolytic reaction
Blood contamination
Sitrat intoxication
Hypotermia

Adverse transfussion
reaction :
Sign
Mild reaction
Localized cutaneous
rection :
Urticatia
Rash

Moderate reaction
Sign :
Flushing
Urticatria
Rigor
Fever

Symptoms

Possible cause

Pruritus

Hypersensitivity
(mild)
Treatment :
administer
antihistamine IM
In worsen treat as
category 2

Anxiety
Pruritus
Mildy dyspnea

Hypersensitifis
(moderate to severe
reaction)
Febrile non hemolytic
transfussion reaction
Possible
contamination of
pathogen

Sign
Severe reaction :
Sign :
Fever
Resetlessness
Hypotension
Tachycardia
Hemoglobinuri
a
Unexplained
bleeding

Symptoms

Possible cause

Pain near infussion

site
Respiratory distress
Low / back pain
Headache
dyspnea

Acute intravascular
hemolysis
Bacterial
contamination
Fluid overload
Anaplylaxis
Trali

During or after transfusion

Increase temperature
Pirogen:
Blood material
Transfusion device
Bacteria metabolism

Relief symptom when stopped transfusion

Type I
Direct IgE sensitized basophils and mast cells

Histamine, SRS-A, Eosinophilic chemotactic factor

(ECF)

Type II
Antibodies (immunoglobulin) mediated

Type III
Complement mediated

Type IV
Direct immune-effector cells not mediated by antibody

Fast and excessive volume tranfusion

Especially in anemia, heart disease,
vascular disease
Could be happened any time normal
volume patient
Fever can precede the overload
simptom

Hemolytic non immune

Donor: blood expired, bacteria contamination, etc
Recipient: mechanical trauma, hypotonic solution

Hemolytic incompatible
Mostly human error !!!
Carreful preparation (labelling, identity check, etc)

Immune hemolytic
AIHA

Citrat accumulation in blood

Calcium ion bound with citrat
Hypocalcemia
PRC citrat as anticoagulant
After > 800 cc PRC give calcium
glukonas

Keep blood donor in room

temperature before tranfused to
recipient

Complication:
Arytmia
Bradycardia

500 cc transfusion 250 cc iron

Benefit for patients with bleeding &
iron deficiency
Repeated transfusion iron
accumulation in system organ
Iron usage cell damage & bleeding

Specific test for transmitted disease

UTD PMI:
Sifilis (1975)
Hepatitis B (1982)
Hepatitis C (not every centre)
HIV (1992)

Live threatening
complications :

Acute intravascular hemolysis

Bacterial contaminations
Fluid overload
Anaphylactic reaction (IgA deficiency)
TRALI

TRALI :
Usually caused by donor plasma that

contains against the patient leucocytes

Rapid failure of pulmonary function within 1
to 4 hours
No spesific treatment, only inspiration or
breathing support

Delayed complications of
transfussion
Complication

Presentation

Treatment

Delayed hemolytic
reactions

5-10 days post

transfussion :
Fever
Anemia
jaundice

Usually no treatment
If hypotension or
oliguria treat as acute
intraavscular
hemolysis

Post transfussion
purpura

5-10 day post

transfussion :
Increased bleeding
tendency

High dose steroid

High dose IVIg
Plasma exchange

Iron overload

Cardiac and liver

failure in chronic
transfussion

Prevention with iron

binding agent

Complication

Presentation

Treatment

Graft vs host disease

10-12 days post

transfussion :
Fever
Skin rash
Diarrhoea
Hepatitis
Pancytopenia

Usually fatal
Supportive care
No spesific therapy