Enumerate the Indications and describe the

appropriate use of blood and blood

products,their complication and management .

Dr R.C.Rongphar
Assistant Professor
O&G DMCH
Why do we need component seperation?

• Allows optimal survival of each constituents.

• Allows transfusing only specific blood
component that the patient requires.
• Transfusion of only specific constituent of
blood needed avoids the use of unnecessary
component which could be contraindicated in
a patient.
 History
• The first documented animal-to-animal (dog)
blood transfusion was performed at Oxford in
1665 by Richard Lower.

• The first animal-to-human blood transfusion in

1667 by Jean Denis.

• The first human-to-human blood transfusion

was performed by James Blundell in 1818.
• In the year 1900, the ABO blood grouping
system was classified by Landsteiner and,
based on this, the first pretransfusion cross-
match was done by Ottenberg in 1907.
• The system of Rh typing was invented by
Landsteiner and Wiener in the year 1940.
• World blood donor day is on 14th of June.
 Blood components
1. Cellular components
2. Plasma components
 Cellular components
1) Red cell concentrate
2) Leukocyte reduced red cells
3) Platelet concentrate
4) Leukocyte reduced platelet concentrate
5) Platelet apheresis
6) Granulocyte apheresis
 Plasma components
1) Fresh frozen plasma (FFP)
2) Single donor plasma
3) Cryoprecipitate
4) Cryo-poor plasma
 Plasma derivatives
1) Albumin (5% and 25%)
2) Plasma protein fractions
3) Factor VIII concentrate
4) Other coagulation factors
5) immunoglobulin
 PACKED RBCs
• Most frequently required and used
• Volume- 250-300 ml
• 1 unit PRBC = 200 ml RBC (65-80%)
• 100 ml additive solution
• 30 ml plasma (20-35%)
• Storage- 1-6OC
• The transfusion of one unit of PRBC increases
the hematocrit by approximately 3%, or the
hemoglobin concentration by 1 g/dL, in a 70-
kg non-bleeding adult.
Indications of PRBC transfusions
 1.Acute anemia
• Acute blood loss
• Surgical hemorrhage
• Traumatic hemorrhage
• Non surgical/non traumatic hemorrhage
• Sepsis
 Acute bood loss
% of blood loss Blood fraction components

<20% crystalloid

20-50% Crystalloid + packed RBCs

>50% Crystalloid + packed RBCs+

albumin/plasma

>50% and bleeding continues Crystalloid + packed RBCs +

albumin/plasma+ FFP
 2.Chronic anemia
• Chronic blood loss (hepatic disorders, bleeding
disorders)
• Decreased erythropoesis (malignancy, drugs
suppressing bone marrow, chemotherapy,
chemotherapy, renal disorders, nutritional)

• Hb < 7 gm/dl if no other comorbidities

• Hb < 8 gm/dl if evidence of CHF, angina or
hypovolemia
 Guidelines for RBC transfusion
• Transfusion trigger is defined as that value of
haemoglobin (Hb) below which RBC
transfusion is indicated.

• Transfusion target is the Hb one aims to

achieve after RBC transfusion.
• Traditionally, the rule of “10/30” was followed
for RBC transfusion, according to which a Hb
level of 10 g/dl or a haematocrit of 30% was
recommended in surgical patients.
• Over the years, the trigger for transfusion has
become more conservative or restrictive.
• In addition, the decision to transfuse RBCs is
based not only on the laboratory values, but
also on the objective evaluation of the
patient's clinical condition and her ability to
compensate for the blood loss.
• Factors that are taken into account before
transfusion-
 the patient's age
 co-morbidities
 severity of illness
 the rate and amount of haemorrhage
• A number of clinical trials in the last few
decades have found the restrictive
transfusion strategy to be as safe as the
conventional (or liberal) strategy.
 Guidelines for transfusion
• Scientific societies-
 American Society of Anesthesiologists
 The Society of Critical Care Medicine
 The American Association of Blood Banks (AABB)
 The American College of Physicians
 The British Committee for Standards in Haematology.

• Most recommend the use of restrictive transfusion

strategy. A summary of these guidelines is as follows:
• Transfusion is rarely indicated when the
hemoglobin concentration is greater than 10
g/dL and is almost always indicated when it is
less than 6 g/dL, especially when the anemia is
acute
• The determination of whether intermediate
hemoglobin concentrations (6–10 g/dL) require
RBC transfusion should be based on the patient's
risk for complications of inadequate oxygenation.
 Post‑operative patients
• In haemodynamically stable post‑operative
surgical patients, the trigger for transfusion is
Hb ≤ 8 g/dl or presence of symptoms of
inadequate oxygen delivery (chest pain of
cardiac origin, orthostatic hypotension or
tachycardia unresponsive to fluid
resuscitation, or congestive heart failure).
Patients in the intensive care unit
In critically ill normovolaemic patients
transfusion is considered at a Hb level of ≤7
mg/dl with a target of 7-9 g/dl, unless specific
co-morbidities or acute illness-related factors
modify clinical decision-making.
 FRESH WHOLE BLOOD

PACKED RED PLATELET RICH

CELLS PLASMA

PLATELET
CONCENTRATE
FRESH PLASMA

Stored at 22 C
FREEZE(FFP)

CRYO CRP
 Fresh frozen plasma
• It contains-
1) All clotting factors
2) Fibrinogen
3) Plasma proteins (particularly albumin0
4) Electrolytes
5) Physiologic anticoagulants (i.e. Protein C,
Protein S, Antithrombin, tissue factor
pathway inhibitor)
• FFP doesnot contain platelets
• FFP is free of erythrocytes and leukocytes.
 Indications of FFP
1) Active bleeding and multiple coagulation
factor deficiency
2) Antithrombin III deficiency
3) Deficiency of factors II, VII, IX, X
4) Acquired coagulation problems like in Liver
disease, vit K deficiency
5) Disemminated intravascular coagulation(DIC)
6) Coagulopathy in massive transfusion
7) urgent reversal of the effect of warfarin
8) used along with plasmapheresis in the
treatment of thrombotic thrombocytopenic
purpura (TTP) and haemolytic uremic
syndrome.
• FFP corrects coagulopathy by replacing or
supplying plasma proteins in patients who are
deficient in or have defective plasma proteins.
• Dose – 10-20 ml/kg in adult
• 1 unit of FFP increases factor levels by 3-5%
• Administered IV
• If FFP not given immediately after thawing, it
should be stored at 1-6 0 C
• If thawed FFP is not used within 24 hours, it
should be discarded.
• Once thawed, the activity of clotting factors,
particularly factor V and factor VIII, decline
gradually
FFP contraindicated when coagulopathy can
be corrected more effectively with specific
therapy and when blood volume can be
adequately replaced with other volume
expanders.
• The decision to transfuse FFP is based on both
presence of bleeding and abnormal laboratory
values of prothrombin time (>1.5),
international normalized ratio (>2) and partial
thromboplastin time (>2 times).

• Plasma should not be used to replace

intravascular volume.
 Platelet concentrate
• Indications –
1) Blood platelet count <50000 / µl and evidence of
significant bleeding
2) Platelet less than 20000 /µl without evidence of
bleed
3) DIC
4) Dengue with thrombocytopenia
5) Bone marrow failure
6) Functional platelet defect and bleeding
 Platelet concentrate
• Platelet transfusion is usually required in a
bleeding patient below a platelet count of 50 ×
109 /L but rarely above 100 × 109 /L.

• With intermediate platelet counts (50–100 x

109/l), the determination should be based on
the patient's risk for more significant bleeding
• Prophylactic platelet transfusion at higher
platelet counts may be indicated for patients
with systemic bleeding or those at increased
risk of bleeding because of coagulation
defects, sepsis, or platelet dysfunction.
• Transfusion of one platelet concentrate will
increase the platelet count by approximately
5000–10000/ µl in the average adult.

• The usual therapeutic dose is one platelet

concentrate per 10 kg body weight.
 Guidelines
• <20000 - always transfuse
• 20000- <30000 – if clinically indicated (e.g.
active bleeding, lumbar puncture,etc)
• 30000-50000 – in certain conditions like
• Intracranial/intraventricular hemorrhage
• Coagulation disorders
• Invasive procedures/surgery
• Alloimmune neonatal thrombocytopenia
• platelet transfusion may be indicated despite
an apparently adequate platelet count if there
is known platelet dysfunction and
microvascular bleeding.
 Cryoprecipitate
• 1 bag of cryoprecipitate contains-
1) Fibrinogen
2) factor VIII
3) Fibronectin
4) Factor XIII
5) von Willebrand factor

Basically, it is a concentrated subset of FFP

components
 What is the difference between
Cryoprecipitate and FFP?
• Cryoprecipitate is made from FFP which is
frozen and repeatedly thawed in a laboratory
to produce a source of concentrated clotting
factors including Factor VIII, von Willebrand
factor and fibrinogen.
 Indications of Cryoprecipitate
1) Congenital/acquired hypofibrinogenemia
2) Congenital/acquired Factor VIII deficiency
3) von Willebrand disease
4) Factor XIII deficiency
5) DIC
Cryoprecipitate Reduced Plasma (CRP)
• It is the plasma remaining once the
cryoprecipitate has been prepared.
• Preparation of the cryoprecipitate removes
much of the fibrinogen, Factor VIII and vWF from
the plasma. However, the vWF enzyme remains.
• This eliminates a source of vWF for multimer
formation and provides the patient with the
deficient enzyme to degrade the existing
multimers.
• Therapeutic plasma exchange (TPE) is the only
disease in which the component is used as
therapeutic treatment.
 Immunoglobulins
• The FDA has approved the use of immunoglobulins for
the treatment of more than 30 disease conditions like-
1) primary immune deficiency
2) B-cell chronic lymphocytic leukemia
3) idiopathic thrombocytopenia purpura
4) pediatric human immunodeficiency virus infection
5) Kawasaki syndrome
6) neuroimmunologic diseases such as Guillain-Barre
syndrome
7) selected obstetric conditions.
 Leukocyte reduced RBC
• Multiple transfusion patients like thalassemia
• Leukemia
• Aplastic anemia
• Immunodeficient patients
• Prevention of CMV transmission in at risk
patients
• Prevention of recurrant FNHTRs
• Prevention of primary alloimmunization to HLA
antigen
 Granulocyte concentrate
• Previously used in
 Septicemia not responding to antibiotics
 Neutrophil count < 0.5*10 9
 Infections in patients undergoing
chemo/radiotherapy for neoplastic diseases

Now, not in practice.

 Adverse transfusion reactions
• Any unfavourable and harmful transfusion
related events occuring in the patient during
or after transfusion of blood or components of
blood is called transfusion reactions.
• Type
1)Immune reactions and non immune reactions
2)Immediate and Delayed reactions
• Common causes of transfusion reactions-
Misidentification of the patient
Improper sample identification
Wrong blood issued
Administration error
Technical error
Storage error
 Immediate adverse reactions
1) Immunological
2) Hemolytic transfusion reaction
3) Febrile non hemolytic transfusion
reactions(FNHTR)
4) Allergic reactions
5) Anaphylaxis
6) Transfusion related acute lung injury (TRALI)
 Immediate non immunological
1) Bacterial contamination
2) Transfusion associated Circulatory overload
3) Metabolic complications (hypothermia,
hyperkalemia, hypocalcemia, DIC)
4) Non immune hemolysis
 Delayed reactions
• Immunological
1) Delayed hemolytic transfusion reaction
2) Transfusion associated Graft versus host
diseases(TA-GVHD)
3) Post transfusion purpura
4) Alloimmunization
• Non immunilogical delayed reactions
1) Iron overload
2) Transfusion transmitted diseases
 MASSIVE BLOOD TRANSFUSION
• Transfusion of 10 or more red cel concentrate
within 24 hours.
• Replacement of 50% of blood voulme within 3
hrs.
• Indication- hypoovlumic shock secondary to
blood loss
 Immediate Haemolytic transfusion
reaction
• Occur within few minutes after starting
transfusion.
• Due to IgM antibody and is usually associated
with the transfusion of ABO incompatible
blood.
• Signs & symptoms-
fever,chills,hypotension,nausea,dyspnea,ARF,s
hock and DIC
• Management-
• Stop transfusion immediately
• Maintain iv line,airway.
• Ensure diuresis
• IVF and vasoactive drugs like dopamine for
hypotension
 Febrile Non haemolytic transfusion
reaction
• Most common and account for over 90% of
transfusion reaction.
• Benign,self limiting reaction due to presence
of antibody to WBC or Platelet antigens and
common in multi transfused patients.
• Occur within minutes of starting the
transfusion.
• Signs & symptoms- fever,chills,malaise
• Management-
• Slow down the transfusion(stop in case of
severe cases)
• Antipyretics
• Can give leukocyte poor red cells
Anaphylactic transfusion reactions
• Severe,life threatening reaction,which occur in rare
patients who are IgA deficient.
• Signs&symptoms-
cough,bronchospasm,dyspnea,nausea,vomiting,urticari
a,hypotension,syncope
• Management-
-Ivf
-Oxygen support
-antihistaminic
-steroids
 Post transfusion purpura
• Occur with platelet concentrate transfusion
• Rapid onset of thrombocytopenia due to
production of platelet allo antibodies
• Usually in multiparous female
• Duration – 7-14 days from transfusion
• Therapy - corticosteroids
 Circulatory overload
• More volume of blood transfused
• Fast rate of blood transfusion
• Leads to heart failure,pulmonary oedema
• Management- inj furosemide
 Iron overload
• Long term complication of RBC transfusion
• aka Transfusion haemosiderosis
• Iron accumulation affect function of heart,liver
,endocrine system
• Signs- muscle weakness,fatigue,mild jaundice
• Therapy- iron chelating agents,deferoxamine
 Laboratory investigation for Transfusion
Reaction
• Eamine the patient pre-transfusion and post-
transfusion plasma from EDTA sample for evidence of
free Hb or increased bilirubin.
• Pink or red discolouration in post transfusion plasma
indicates the presence of free Hb due to red cell
destruction.
• Yellow discolouration of the sample drawn 6-8hr after
transfusion indicates increased bilirubin.
• Perform DCT on the pre and postransfusion sample
• Check urine(post transfusion) 1st sample
 Transfusion transmissible infections
• HIV I & II
• HBV(HAV)
• HCV
• Syphilis
• Malaria
• CMV
• SARS etc
Bacterial contamination & septic shock
• Due to contamination of blood especially
platelets at collection,processing,storage in
blood bank or ward.
• Bacteremia in donor
• Endotoxines
• Management- stop transfusion,start ivf,broad
spectrum antibiotics
Thank you.