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Transfusion Medicine
 What is Transfusion
Medicine?
• The practice of blood transfusion and blood
conservation, complementary activities that
ensure the best balance between safety and
convenience during emergency care or surgery.
• Encompasses issues of blood donation,
immunohematology and other laboratory testing,
transfusion practices, therapeutic apheresis, stem
cell collections, cellular therapy, and coagulation.
 Immunohematology
• BLOOD BANKING
• refers to the serologic, genetic, biochemical and
molecular study of antigens associated with
membrane structures on the cellular
constituents of the blood, and immunologic
properties and reactions of all blood
components and constituents.
• Area of laboratory medicine dealing with
preparing blood and blood components for
transfusion as well as selection of appropriate,
compatible components for transfusion
Transfusion Medicine: An
Overview
 Transfusion Overview
• Integral part of medical treatment
• Most often used in Hematology/Oncology, but
other specialties as well (surgery, ICU, etc)
• Objectives
– Blood components
– Indications for transfusion
– Safe delivery
– Complications
 Donor Recruitment and
Eligibility Screening
• National Voluntary Blood Services Program (NVBSP)
• Basic requirement of a potential blood donor:
• Weight: At least 110 lbs (50 kg).
• Blood volume collected will depend mainly on you body
weight.
• Pulse rate: Between 60 and 100 beats/minute with
regular rhythm.
• Blood pressure: Between 90 and 160 systolic and 60 and
100 diastolic.
• Hemoglobin: At least 125 g/L.
 Blood Components
• Prepared from Whole blood collection or apheresis
• Whole blood is separated by differential centrifugation
– Red Blood Cells (RBC’s)
– Platelets
– Plasma
• Cryoprecipitate
• Others
• Others include Plasma proteins—IVIg, Coagulation
Factors, albumin, Anti-D, Growth Factors, Colloid volume
expanders
• Apheresis may also used to collect blood components
Apheresis
• withdrawal of blood from
a donor's body, removal
of one or more
components (as plasma,
blood platelets, or white
blood cells) from the
blood, and transfusion of
the remaining blood back
into the donor
APHERESIS
 Importance of Component
Separation
• Separation of blood into components allow
optimal survival of each constituent
• Component separation allows transfusion of
only specific desired component to the
patient  avoid the use of unnecessary
component
• By using blood components, several patients
can be treated w/ the blood from 1 donor
Blood Bags
 Action of Ingredients of
Anticoagulant Solution
• Citrate phosphate • CITRATE: prevents
dextrose (CPD): contains coagulation by chelating
citric acid, Na citrate, Ca
monobasic phosphate • Phosphate: prevents fall
and dextrose to preserve in pH
blood for up to 21 days • DEXTROSE: supports ATP
• CPDA -1: same as CPD + generation by glycolytic
adenine to preserve blood pathways
for up to 35 days • ADENINE: synthesizes and
increases ATP to extend
shelf-life of RBC to 35
days
 Blood Bank Centrifuge
• Centrifugation is the 1st step of blood component
preparation
- a separation process which uses the action of
centrifugal force (moving away from the center)
to promote accelerated settling of particles in a
solid-liquid mixture
• Depends on 2 factors:
a. speed of centrifugation
b. duration of centrifugation
 Blood Bank Centrifuge
1 . LIGHT SPIN
- 4170 rpm/2 min:
platelet rich plasma
2. HEAVY SPIN
- 5000 rpm/7 min:
leukocyte-poor rbc or cell
free plasma
- 5000 rpm/5 min: PRBC
and platelet concentrate
- 4170 rpm/10 min:
cryoprecipitate
Blood Bank Centrifuge
Differential Centrifugation
First Centrifugation
Closed System

Whole Blood Satellite Bag Satellite Bag

Main Bag 1 2
First

Platelet-rich
RBC’s Plasma
Differential Centrifugation
Second Centrifugation

RBC’s Platelet-rich
Plasma
Second

Platelet Plasma
RBC’s Concentrate
BLOOD COMPONENTS
 Whole Blood
• Storage
– 4° for up to 35 days
• Indications
– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations
– Use filter as platelets and coagulation factors will not
be active after 3-5 days
– Donor and recipient must be ABO identical
RBC Concentrate (PRBC)
• Storage
– 4° for up to 42 days, can be frozen
• Indications
– Many indications—ie anemia, hypoxia, etc.
• Considerations
– Recipient must not have antibodies to donor RBC’s
(note: patients can develop antibodies over time)
– Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
– Usually transfuse over 2-4 hours (slower for chronic
anemia
 Platelets
• Storage
– Up to 5 days at 20-24°C
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations
– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by
50,000
– Donor and Recipient must be ABO identical
 Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml)
• Storage
– FFP--12 months at –18 degrees or colder
• Indications
– Coagulation Factor deficiency, fibrinogen replacement,
DIC, liver disease, exchange transfusion, massive
transfusion
• Considerations
– Plasma should be recipient RBC ABO compatible
– In children, should also be Rh compatible
– Account for time to thaw
– Usual dose is 20 cc/kg to raise coagulation factors
approx 20%
 Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is thawed at 4°
• Storage
– After collection, refrozen and stored up to 1 year at -18°
• Indication
– Fibrinogen deficiency or dysfibrinogenemia
– Von Willebrands Disease
– Factor VIII or XIII deficiency
– DIC (not used alone)
• Considerations
– ABO compatible preferred (but not limiting)
– Usual dose is 1 unit/5-10 kg of recipient body weight
 Granulocyte Transfusions
• Prepared at the time for immediate transfusion
(no storage available)
• Indications – severe neutropenia associated with
infection that has failed antibiotic therapy, and
recovery of BM is expected
• Donor is given G-CSF and steroids
• Complications
– Severe allergic reactions
– Can irradiate granulocytes for GVHD prevention
 Leukocyte Reduction Filters
• Leukoreduction: process
in which wbcs ordinarily
present in circulation are
intentionally reduced in #
through filters or
centrifugation
• Used for prevention of
transfusion reactions
• May reduce WBC’s by
5-10%
• Does not prevent Graft
Verses Host Disease
(GVHD)
 RBC Transfusions
Preparations
• Type
– Typing of RBC’s for ABO and Rh are determined for
both donor and recipient
• Screen
– Screen RBC’s for atypical antibodies
– Approx 1-2% of patients have antibodies
• Crossmatch
– Donor cells and recipient serum are mixed and
evaluated for agglutination
 RBC Transfusions
Administration
• Dose
– Usual dose of 10 cc/kg infused over 2-4 hours
– Maximum dose 15-20 cc/kg can be given to
hemodynamically stable patient
• Procedure
– May need Premedication (Tylenol and/or Benadryl)
– Filter use—routinely leukodepleted
– Monitoring—VS q 15 minutes, clinical status
– Do NOT mix with medications
• Complications
– Rapid infusion may result in Pulmonary edema
– Transfusion Reaction
 Platelet Transfusions
Preparations
• ABO antigens are present on platelets
– ABO compatible platelets are ideal
– This is not limiting if Platelets indicated and type
specific not available
• Rh antigens are not present on platelets
– Note: a few RBC’s in Platelet unit may sensitize the Rh-
patient
 Platelet Transfusions
Administration
• Dose
– May be given as single units or as apheresis units
– Usual dose is approx 4 units/m2—in children using 1-2
apheresis units is ideal
– 1 apheresis unit contains 6-8 Plt units (packs) from a
single donor
• Procedure
– Should be administered within 20-40 minutes
– Filter use
– Premedicate if hx of Transfusion Reaction
• Complications—Transfusion Reaction
COMPATIBILITY TESTING
• Done pre-transfusion to ensure best
possible results of a blood transfusion
• Includes:
a. ABO-Rh blood typing
b. Antibody screening
c. Crossmatching
The Blood Group Systems

Inheritance and Genetics

 Basics on Genetics

• Genetics: study of inheritance

• Chromosomes: a threadlike structure of nucleic
acids and protein found in the nucleus of most
living cells, carrying genetic information in the
form of genes.
- Total # of chromosomes: 23 pairs (46)
a. autosomal (nonsexual) chromosome: 22 pairs
of chromosomes, same for males and females
b. sex-linked chromosome: 1 pair; either X or Y,
determines gender: XX (female), XY (male)
 Genes
• Segments of DNA that contain the code for
a specific protein that functions in 1 or
more types of cells in the body
• Contained in chromosomes, which are
mainly in the cell nucleus
• Humans have about 20,000-25,000 genes
 Genotype vs Phenotype
GENOTYPE PHENOTYPE
• Genetic make-up of an • Outward expression of
individual genes
• genes determine which • Observable traits
blood group antigens are • Blood group antigen typing
present on the RBC indicates a persons
membrane. phenotype
• Eg. AA, AO • Eg. Group A is a phenotype.
 Basics of Genetics
• Locus: Location of a gene on a
chromosome
• Allele: Variation of a gene that produces an
alternative form of the gene
• Homozygous: 2 identical alleles at a locus
(AA, BB, RR, rr)
• Heterozygous: 2 different alleles at a locus
(AO,BO, Rr)
 Dominant vs Recessive
Alleles
• Since human cells carry 2 copies of each chromosome,
they have 2 versions of each gene. These different
versions of a gene are called ALLELES.
• DOMINANT ALLELES: show their effect even if the
individual only has 1 copy of the allele (heterozygous)
• CODOMINANCE: both alleles are dominant and expressed
equally (eg. A and B blood groups)
• RECESSIVE ALLELES: only show their effect if the
individual has 2 copies of the allele (homozygous)
 MOM MOM

DAD DAD
 History of Transfusions
• Blood transfused in humans since mid-
1600’s
• 1828 – First successful transfusion
• 1900 – Landsteiner described ABO groups
• 1916 – First use of blood storage
• 1939 – Levine described the Rh factor
 History of Blood Groups and
Blood Transfusions
• Experiments with transfusions have been carried out for
hundreds of years
• 1901: Austrian Karl Landsteiner discovered human blood
groups blood transfusion became safer
• He found that mixing blood from 2 individuals can lead
to blood clumping  clumped RBCs can crack and cause
toxic reactions and can be fatal
• He discovered that blood clumping was an immunological
reaction (occurs when the recipient of blood transfusion
has Abs against the donor blood cells)
• Made it possible to determine blood types w/c paved the
way for safe blood transfusions  1930 Nobel Prize in
Physiology or Medicine
What are the different blood
groups?
• The differences in human blood are due to the
presence or absence of certain molecules called
antigens and antibodies
• The Ags are located on the surface of the RBCs
and the Abs are in the plasma
• Individuals have different types of combinations
of these molecules
• The blood group you belong to depends on what
you have inherited from your parents
What are the different blood
groups?
• There are 32 blood group systems recognized today
by the International Society of Blood Transfusion
(ISBT)
• The ABO and Rhesus (Rh) systems are the
most important ones used for blood transfusions.
• Not all blood groups are compatible with each other.
Mixing incompatible blood groups leads to blood
clumping or agglutination, which is dangerous for
individuals.
 ABO Blood Group System
• Blood types are inherited genetic traits
• ABO genes: found on chromosome 9
• A and B Ags: begin to appear on fetal RBCs
at 6 wks AOG and reach adult level at age 4
- also found on platelets, endothelium,
kidney, heart, lung, bowel, pancreas
ABO Blood Group: DONUTS & SPRINKLES

*********** ^^^^^^^^^
************* ^^^^^^^^^^^^^
**** **** ^^^^ ^^^^^
************* ^^^^^^^^^^^^^^
********** ^^^^^^^^^

“A” “B”
* = A Ag
*^*^*^*^*^* ^ = B Ag
*^*^*^*^*^*^*^
^*^*^ *^*^
*^*^*^*^*^*^*
^*^*^*^*

“AB” “O”
 Carbohydrate Portion of
ABO Ag

They look structurally similar BUT have very different chemical properties
LANDSTEINER’S LAW
1. If an agglutinogen (Ag) is present on the
RBC membrane, the corresponding
agglutinin (Ab) must be absent in the
plasma
2. If an agglutinogen is absent on RBC
membrane, then the corresponding
agglutinin must be present in the plasma
 ABO Antibodies
• Anti-A, Anti-B, Anti-A,B
• Begin to appear at 4 months of age, reach adult
levels by age 10 and may fade w/ advanced age
• Almost all normal healthy individuals have
naturally occurring Abs to the ABO Ags that they
lack
- thought to arise without antigenic stimulation
- IgM Abs
 ABO Gene and Genetics
• The ABO blood type is controlled by a
single gene (ABO gene) with 3 types of
alleles: i, IA and IB
• The designation I stands for
isoagglutinogen, another term for antigen
• The gene is located on the long arm of
chromosome 9: (9q34)
 WTH??: What the H?
• H Antigen: the precursor and building block
for the production of the Ags within the ABO
blood group located in chromosome 19
- found in virtually all RBCs
• The presence or absence of the ABH Ags on
the RBC membrane is controlled by the H gene
• Must be HH or Hh to be expressed
A B
H H H

“A” “B” “O”

 Bombay Phenotype (hh)
• Rare blood type first • Lack H gene w/c
discovered in Bombay, normally produces H
India by Dr. Y.M. Ag (precursor of A
Bhende in 1952 and B Ags)  A and B
• H Ag deficiency (h/h Ags cannot be
or Oh) is found in 1 in expressed
10,000 individuals in • Serum contains anti-A,
India, 1 in 1M people anti-B and anti-H
in Europe
 Bombay Phenotype
• Can donate RBCs to
any member of ABO
blood group but the
cannot receive blood
from any ABO blood
grouping except from
Bombay blood group
people
Thank you!