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SWASTHYA KALYAN BLOOD BANK FOR DOCTORS

ALL ABOUT BLOOD COMPONENTS

Background
Blood may be transfused as whole blood or as one of its components. Because patients seldom require all of the components of Whole Blood, it makes sense to transfuse only that portion needed by the patient for a specific condition or disease. This treatment, referred to as "blood component therapy," allows several patients to benefit from one unit of donated whole blood. Blood components include red blood cells, plasma, platelets, and cryoprecipitated antihemophilic factor (AHF).
On the other hand, Whole blood contains red blood cells and plasma. It is often used for open-heart surgery and may also be used for exchange transfusions (complete replacement of a baby's blood) in newborn babies with hemolytic disease of the newborn. This product is otherwise not commonly required. Let us have a detailed look into the usage of whole blood:

Indication
Contra-indication
Administration

dot Exchange transfusion
dot Patients needing red cells transfusion where red cell concentrates or suspensions are not available and WB is available in Blood banks not preparing components.
Risk of volume overload in patients with:
dot Chronic anaemia
dot Incipient cardiac failure
dot Must be ABO and Rh compatible with the recipient
dot Transfusion should be completed within 4 hrs of starting
dot Medication should never be added to a unit of blood
Whole blood may be separated into the following components:
dot Red cell concentrate
dot Platelet concentrates (prepared from whole blood donations)
dot Platelet concentrates (collected by plateletpheresis)
dot Fresh Frozen Plasma
dot Cryoprecipitate
dot Plasma
The components

1. Red cell concentrate

Red blood cells carry oxygen to the tissues. Packed red blood cells have had most of the plasma removed from the whole blood

Indication:
dot For replacement of red cells in anaemic patients
dot Use with crystalloid replacement fluids or colloid solution in acute blood loss
Administration

Same as whole blood-To improve transfusion flow, normal saline (50-100ml) be added using a Y-pattern giving set.

2. Platelet concentrates (prepared from whole blood donations)

Units of platelets are prepared by using a centrifuge to separate the platelet-rich plasma from the donated unit of whole blood. The platelet-rich plasma is then centrifuged again to concentrate the platelets further.

Indication
dot Treatment of bleeding due to
1. Thrombocytopenia
2. Platelet function defects
dot Prevention of bleeding due to thrombocytopenia such as in bone marrow failure.
Contra-indication
dot Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant pre-operative platelet deficiency
dot Not indicated in:
1. Idiopathic autoimmune thrombocytopenic purpura(ITP)
2. Thromobotic thromocytopenic purpura (TTP)
3. untreated disseminated intravascular coagulation (DIC) I
4. Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism
Administration
dot Platelet concentrates should be infused as soon as possible, generally within 4 hours. (Half life of Platelets at R.T. is 6 hours)
dot Must not be refrigerated before infusion as this reduces platelet function.
dot 4-6 units of platelet concentrates should be transfused through a fresh standard blood administration set.
dot Special platelet infusion sets are not required.
dot Platelet concentrates prepared from Rh D Positive donors should not be given to a Rh D negative potential child bearing female.
dot Platelet concentrates that are ABO compatible should be given whenever possible.
3. Platelet concentrates(collected by plateletpheresis)

In this process, blood is drawn from the donor into an apheresis instrument, which, using centrifugation, separates the blood into its components, retains the platelets, and returns the remainder of the blood to the donor. The resulting component contains about six times as many platelets as a unit of platelets obtained from whole blood.

Indication
dot Platelet concentrates collected by apheresis are, generally, equivalent to six units of platelet concentrates prepared from whole blood.
dot If a specially typed compatible donor is required for the patient, several doses may be obtained from the selected donor.
Administration

Same as for recovered donor platelets, but ABO compatibility is more important: High titre counts of A or B in the donor plasma used to suspend the platelets may cause low grade haemolysis of recipient's red cell.

4. Fresh Frozen Plasma

Fresh frozen plasma is plasma which was frozen and stored shortly after it was obtained from the blood donor. Fresh frozen plasma contains many clotting factors and is often used alone or with cryoprecipitate to replace the low levels of clotting factors.

Indication

dot Replacement of multiple coagulation factor deficiencies e.g:
1. Chronic Liver disease
2. Warfarin anticoagulant overdose
3. Depletion of coagulation factors in patients receiving large volume of whole blood
dot Disseminated intravascular coagulation (DIC)
dot Thrombotic Thrombocytopenic purpura (TTP)
dot Antithrombin III deficiency
dot Congenital or acquired coagulation deficiency
dot Use of FFP with red cells has largely replaced the need of fresh blood

Contra-indication

dot Hypovolaemia alone is not an indication for use
dot Hypoproteinemia
dot Source of immunoglobulin
dot Prothrombin time less than 18 seconds
Administration
dot Must normally be ABO compatible to avoid risk of haemolysis in recipient.
dot No cross matching needed.
dot Before use, should be thawed in water which is between 30 °C and 37° c higher temperatures will destroy clotting factors and proteins.
dot Once thawed, should be stored in a refrigerator at 2°C- 6°C
dot Infuse using a standard blood giving set as soon as possible after thawing.
dot Labile coagulation factors rapidly degrade; use within 6 hours of thawing.
5. Cryoprecipitate

Cryoprecipitate is the part of the blood which contains only certain clotting factors such as factor VIII (deficient in hemophilia A), von Willebrand factor, and fibrinogen.

Indication

dot As an alternative t Factor VIII concentrate in the treatment of inherited deficiencies of:
1. Von willebrand Factor (von Willebrand's disease)
2. Factor VIII (Haemophilia A)
3. Factor XIII
dot As a source of fibrinogen in acquired coagulopathies,e g: Disseminated intravascular coagulation (DIC)

Administration

dot If possible, use ABO compatible product, Rh type is insignificant.
dot No compatibility testing is needed.
dot After thawing, infuse as soon as possible through a Standard blood administration set.
dot Must be infused within 6 hours of thawing.
6. Plasma

Plasma can be used as a source of Albumin when commercially prepared Albumin is not available. It is far cheaper and contains indigenous immunoglobulin.

Indication

dot Disseminated intravascular coagulation (DIC) Thrombotic Thrombocytopenic purpura (TTP)
dot Antithrombin III deficiency
dot Congenital or acquired coagulation deficiency

Contra-indication

dot Hypovolaemia alone is not an indication for use
dot Hypoproteinemia
dot Source of immunoglobulin
dot Prothrombin time less than 18 seconds

Administration

dot Must normally be ABO compatible to avoid risk of haemolysis in recipient.
dot No cross matching needed
GUIDELINES FOR BLOOD TRANSFUSION

Introduction

This section of our website is devoted to encouraging a well-organized blood transfusion service (BTS), which is a prerequisite for the safe and effective use of blood and blood products. For efficient management of blood transfusion and ensuring safety of blood supply, the hospital needs adequately trained manpower, infrastructural facilities, including supplies and equipment.

Guidelines

A. Requesting for blood from Blood bank

The first step is to fill up the Request Form for obtaining either whole blood or components. To request Blood from Swasthya Kalyan Blood Bank, click here to download the form.
The form should be carefully filled and it should be submitted at the Blood bank along with the patient's (recipient's) blood sample. The blood sample should be obtained in a stopper plain vial containing anticoagulant. It must bear a label carrying the following details:

dot Patient's full name (Cross-match-slip)
dot Identification number
dot Name of hospital
dot Ward/bed number
dot Date and time
dot Phlebotomist's signature/ initials

When recipient's blood sample is received in the Blood Bank laboratory, a qualified staff confirms, if the information on the label and on the transfusion request form are identical. In case of any discrepancy or doubt a new sample will have to be submitted.

B. Receiving Blood From Blood Bank

The blood bag which is issued from the bank will bear the following details:

dot A label or a tag with patient's name,
dot Hospital name,
dot Identification number, Blood unit number (assigned by the collecting/intermediary facility) Interpretation of the cross matching test
Blood Bank must provide blood cross -matching report form along with the blood bag. The cross matching report form bears the details like: Patient's first name with surname, Age, Sex, Identification number, Bed number and ward, ABO and Rh(D) type. So it is very important to tally the details given on blood bag with the form. Blood once issued is not taken back by the Blood Bank, especially if the cold chain is broken.
SPECIAL CASE: Urgent Requirement of Blood

In some cases, delay in procuring blood can jeopardize the patient's life. Under such circumstances, Blood or blood components can be immediately issued by the Blood Bank without completing the routine processes like cross matching tests, which can cause delay.
To request for Blood on urgent basis, the treating physician can give a signed written request stating that the clinical condition of the patient requires urgent release of blood before completing ABO and Rh(D) tests and compatibility testing. Under such circumstances,

dot Patients whose ABO and Rh(D) type is not known should receive red cells of group O Rh(D) negative if available, otherwise O Rh(D) positive blood should be used.
dot Patient or Recipient whose ABO, Rh(D) type has been determined should receive ABO and Rh(D) specific blood group whole blood or red cells before the tests for compatibility have been completed.
The blood container as well as the Cross-matching report received from the bank will have a label indicating that compatibility testing has not been completed at the time of issue.
C. Transfusion of Blood and Blood Components

Here are the steps that must be followed for transfusing the Blood and components:

dot i) Taking the consent It is the duty of the physician to inform the patient and his/her relatives about the need for blood transfusion as well as about any alternatives (drugs, therapy etc) if present. He must also explain them the risks involved with transfusion as well as with the alternative treatment. The patient must give a written consent in the language he / she understands best incase the patient is unconscious or is a minor, then the closest kin should sign the informed consent.
dot ii) Some Pre-transfusion checks All the following checks must be carried out:
dot Inspect the blood or blood component for Leakage, Unusual colour e.g. black or purple (may indicate haemolysis), Unusual cloudiness or particulate matter or Presence of large clots. If any of the above are present, the unit must not be used and should be returned to the Blood Bank. Check for expiry date of unit.
dot Positively identify the patient before transfusion by confirming name/surname and patient identification number
dot The blood group on the Blood unit must be compatible with the blood group of the patient indicated on the compatibility label attached to the blood pack (if in doubt, ring the Blood Bank)
iii) Supervision of the Transfusion Process
Precautions to be Taken
dot Blood and blood components should be maintained at the optimum temperature before transfusion.
dot The transfusion should be given with sterile, pyrogen free and disposable transfusion set with filter. The transfusion should be started immediately on receipt of blood.
dot Warming of blood to body temperature should be done in case of rapid transfusion, massive transfusion, exchange transfusion in infants and patients with cold agglutinins. Warming of blood should be accomplished using a blood warming device attached to the transfusion set. The warming system should be equipped with a visible thermometer and ideally with an audible alarm system. Blood should not be warmed above 37°C.
dot Medication should never be added to the whole blood or components. Similarly no other intravenous fluid except 0.9% sodium chloride Injection l.P. should be administered with blood components.
dot Red cells should not be administered with I / V solution containing calcium, dextrose or Ringer's solution.
Transfusion should be prescribed and administered under medical direction. The doctor / transfusionist should observe the patient for an appropriate time at the initial stage and during the transfusion to observe any evidence of untoward reaction and to regulate the speed of Transfusion.
To ensure good clinical practice (GCP) the user hospital should formulate a hospital transfusion committee.
Product to be Transfused
Special consideration
Red cell Transfusion
dot Red cell transfusion should be ABO & Rh (D) compatible.
dot Transfusion of one unit of red cells should not take longer than 4 hours.
dot The viscosity of red cell concentrate should be reduced by the addition of small volume (50 ml) of sterile normal saline through one limb of a Y infusion set.
Fresh Frozen Plasma
Plasma transfusion should be ABO compatible. Cross matching tests are usually not performed on plasma products. Products that have been thawed should be infused without delay to avoid bacterial proliferation. This is thawed at temperature of 37°C. If it is used as a source of labile coagulation factors, it should be used immediately and in any case within 6 hours of thawing. If used for a purpose other than coagulation factor replacement it should be transfused within 24 hours after it is thawed and stored at 1-6°C.
Cryoprecipitate
The component should be thawed at temperature of 37°C and should be used immediately. ABO compatibility should not be a must.
Single donor plasma
It should be transfused within 24 hours after it is thawed and stored at 1-6°C.
Platelets and Leucocytes
dot Platelets should be ABO-identical but in absence of availability of ABO compatible platelets, ABO-incompatible platelets can be used. If there is visible red cell contamination in platelet and leucocytes concentrate, group specific and cross matched product should be used.
dot Platelets and leucocytes should be administered through a standard filter. Micro aggregate filters should not be used for these products.
dot Platelets and leucocytes should be infused at 1-2 mI/minute or as tolerated by the patient.
dot Granulocyte concentrates should be irradiated before transfusion.
ADVERSE TRANSFUSION REACTIONS AND THEIR MANAGEMENT

A Background

Blood transfusion is an essential part of patient care. When used correctly, it saves lives and improves health. However, blood transfusion carries a potential risk of acute or delayed complications and transfusion transmitted infections and should be prescribed only to treat conditions associated with significant morbidity or mortality that cannot be prevented or managed effectively by other means.
In medicine, a transfusion reaction is any adverse event which occurs because of a blood transfusion. These events can take the form of an allergic reaction, a transfusion-related infection, hemolysis related to an incompatible blood type, or an alteration of the immune system related to the transfusion. This section of our website deals with the adverse transfusion reactions and their management.

Cause of the Reaction

Transfusion reaction is a problem that occurs after a patient receives blood. The immune system launches a response against the new blood cells or other parts of the transfusion. In brief, this occurs when transfusions of a different Blood type than that of the patient is done. This may occur from errors in matching Blood or from the use of incompletely matched Blood in an emergency

Signs & Symptoms

The most common signs and symptoms are -Chills and fever; backache or other aches and pains; hives and itching. In more serious situations, signs like Blood cell destruction (hemolysis), shortness of breath, severe headache, chest or back pain and Blood in the urine, can be seen.

Types of Adverse Transfusion Reactions

Adverse events associated with blood transfusion therapy can be classified based on time of onset and etiology. See the flowchart below:

Acute transfusion reactions generally occur during or within 2 hours of transfusion. Whereas, delayed Transfusion reactions occur after few days or months. Transfusion reaction manifestations may vary with the type of blood product transfused and the clinical condition of the recipient. So the adverse transfusion reaction can be categorized as:

dot Acute
dot Delayed
Now let us understand the type of reaction evoked and how one can manage it.
Category
Reaction
Management
dot Category 1: Mild Reaction
dot Mild hypersensitivity allergic, without urticarial reaction
dot Slow the transfusion.
dot Give an antihistamine: e.g. chlorpheniramine 0. 1 mg/kg by intramuscular injection.
dot Continue the transfusion at the normal rate if there is no progression of symptoms after 30 minutes.
dot If there is no clinical improvement within 30 minutes or if signs and
dot Symptoms worsen; treat the reaction as a Category 2 reaction.
dot Category 2: Moderate Severe Reaction
dot Moderate to severe hypersensitivity (Severe urticarial reaction)
dot Febrile non-Haemolytic reaction
dot Bacterial contamination Pyrogens
dot Stop the transfusion. Replace the giving-set and keep the 1V line open with normal Saline.
dot Notify the doctor responsible for the patient and the blood bank immediately
dot Send the blood unit with giving set, freshly colleted urine and new blood
dot Samples (1 clotted and 1 anti-coagulated from the vein opposite the infusion site with an appropriate request form to the blood bank for investigations
dot Administer antihistamine IV or IM (e.g. chlorpheniramine 0.01 mg/kg or equivalent) and an oral or rectal antipyretic (e.g. paracetamol 1(1 mg/kg: 500 mg 1 mg in adults). Avoid aspirin in thrombocytopenic patients.
dot Give IV Corticosteroids and branchodilators if there are anaphylactoid features (e.g. broncospasm, stridor)
dot Collect urine for the next 24 hours for evidence of haemolysis and send to the laboratory
dot Category 3: Life Threatening Reaction
dot Acute intravascular haemolysis
dot Bacterial contamination and septic shock
dot Fluid overload Anaphylactic reaction Transfusion associated lung injury
dot Stop the transfusion. Replace the giving-set and keep the 1V line open with normal Saline.
dot Infuse normal saline to maintain systolic BP (initial 20-30 ml /kg). If hyposensitive, give over 5 minutes and elevate patient's legs.
dot Maintain airway and give high flow oxygen by mask
dot " Give 1:1000 adrenaline 0.01 mg/kg body weight by intramuscular injection.
dot Give 1V Corticosteroids and branchodilators if there are anaphylactoid features (e.g. broncospasm, stridor)
dot Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent
dot Notify the doctor responsible for the patient and the blood bank immediately.
dot Send blood unit with giving-set, fresh urine sample and new blood samples (1 clotted and 1 anti-coagulated) from vein opposite infusion site with appropriate request form to blood bank and laboratory for investigations.
dot Check a fresh urine specimen visually for signs of haemoglobinuria (red or pink urine)
dot Start a 24 hour urine collection and fluid balance chart and record all intake and output. Maintain fluid balance.
dot Assess for bleeding from puncture sites or wounds. If there is clinical or laboratory evidence of DIC, give platelet concentrates.
Delayed Transfusion Reaction
Category
Reaction
Category 1: Transfusion Transmitted Infection
dot HIV I & HIV 2
dot HTLV I & II
dot Hepatitis B & C
dot HSyphilis
dot Chaga's disease
dot Malaria
dot Cytomegalovirus
dot Other infection like CjD, Human parovirus B19 etc Category 2: Delayed Haernolytic Reaction
dot Alloimmunization
dot T-GVH disease
dot Iron overload