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S2 L5: Transfusion Medicine by Dr. Ma. Mystica Flodalyn T. Bautista SSSeeepppttteeem

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HIGLIGHTS OF TRANSFUSION MEDICINE Criteria for Blood Donation

 1628- England 1. Medical History
o William Harvey discovered blood circulation o All donors are required to complete a health questionnaire and blood
o Earliest known blood transfusion (BT) attempted safety form (Confidential interview)
 1665- England 2. Physical Health
o 1st recorded successful BT (dogs  other dogs) 3. Donor Information
 1667 a. Name
o Jean- Baptiste Denis (France) b. Date and time of donation
o Richard Lower (England) c. Address
 Sucessful transfusions from lambs to humans d. Telephone number
 Law prohibited BT from animals to humans due to reactions e. Gender
 James Blundell (England) f. Age and/or date of birth
o 1818  Less than 17 yo requires written consent from parent/ guardian
 Patient for the treatment of post partum hemorrhage  No upper age limit – elderly donors may be accepted at the
 Patient’s husband as a donor discretion of the blood bank (BB) physician
o 1825-1830 4. Who is a potential donor?
 Performed 10 BT; 5/10 proved to be beneficial to his patients o In good health and feeling well on the day of donation
 1873-1880 o Not on prescribed medication that would cause the donor a problem
o US physicians transfused milk (from cows, goats and humans) when donating or that would affect the recipient
 1884 o Normal hemoglobin (>12.5 mg/dL)
o Saline infusion replaced milk as a blood substitute due to the o Weight: at least 50 kg for 450 mL donations
increased frequency of adverse reactions to milk o Pulse rate: regular rhtyhm, 60-100 bpm
 1900 o Blood pressure
o Karl Landsteiner (Austrian) discovered the 1st 3 human blood  Systole: 90-160 mmHg
groups – A, B and O (formerly A, B and C)  Diastole: 70-100 mmHg
o His colleagues added AB the 4th tyoe in 1902
Deferral
 1916
o World War I  Permanent
1. Cancer
 Problem with preservation and transport of blood
2. Cardiac diseases
o Francis Rous and J.R. Turner
 Use of citrate-glucose solutionpermitted storage of blood for  Arryhtmia, congestife heart failure, etc.
3. Severe lung diseas
several days after collection
 Establishment of the first blood depot by the British during WWI  Complicated asthma, bronchiectasis, etc.
4. History of viral hepatitis
 1940 (World War II)
 (+) HBs Ag
o Use of preservative solutions
 Reactive for Anti- HBc
o US program for the collection of blood : “Plasma for Britain”
 Past/present evidene of Hepatitis C infection
 American Red Cross collected 13 M blood units during WW II
 Donor involved in post transfusion hepatitis
 1947
5. History of jaundice of unknown origin, or other liver diseases
o Blood banks established in major cities across the US and blood
6. Use of prohibited drugs (past or present)
donation was promoted to the public as a way of fulfilling one’s civic
7. Sexually transmitted disease (past or present)
responsibility
8. Prolonged bleeding
 Hemophilia A or B
VOLUNTARY BLOOD DONATION
9. Unexplained weight loss of more than 5kg over 6 months
10. Chronic alcoholism
Transfusion
11. Prostitution
 A multi-step process
12. High risk sexual behavior or continuing exposure to persons with
1. Recruitment 4. Processing 7. Transportation
hepatitis, HIV, and other STDs including inmates of mental institutions
2. Collection 5. Prescribing 8. Transfusion
and prisons
3. Testing 6. Issuing 9. Follow-up
13. Chronic eczema, dermatitis, recurring boils
 Purpose
14. Cardiovascular and kidney diseases
1. Quickly restore blood volume post hemorrhage, burns or injuries
15. Convulsion, epilepsy or other mental diseases
and combat shock
 3 years
2. Treat severe anemia
1. Malaria
3. Promote hemostasis

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 12 months Apharesis
1. Operation or blood transfusion  Involves removal of whole blood from a patient or donor
2. Ear piercing, tattooing, needle puncture  One of the separated components is then withdrawn and the remaining
3. Exposure to a sexual partner or close household contact with HIV or components are re-transfused into the patient or donor
hepatitis
4. Rabies vaccine
 9 months PRE-TRANSFUSION TESTING
1. Child birth
 3 months Tests on All Units Collected for Transfusion
1. Whole blood donation
2. Weaning 1. ABO typing
 2 months o Components to be transfused and permissible donor type
1. Anti- acne medication (retinoids, retinoic acid) Single donor Single donor
Px Whole Cryo
RBC Plasma full volume reduced
 1 month type blood
platelets volume plt
ppt
1. Vaccine: German measles O O O Any Any Any Irrel
 2 weeks A A A,O A,AB A,AB Any Irrel
1. Acute febrile illness (2-3 weeks) B B B,O B,AB B,AB Any Irrel
AB AB Any AB AB Any Irrel
2. Vaccine: Measles, OPV, mumps
 12 hours
1. Alcohol intake
 Other conditions for temporary deferral   The Formation of A, B and H Antigens
1. After skin lesion has completely healed ABO genes code not for the antigen themselves
2. After full recovery from febrile illness but for the production of glycosyl transferase
3. When TB is completely cured that add immunodominant sugars that define the blood type

Gene Transferase Sugar

No deferral
H Fucosyltransferase L-fucose
 Killed vaccines A Acetylgalactosaminyltransferase N-acetylgalactosamine
1. Injectable polio vaccine B Galactosyltransferase D-galactose
2. Hepatitis B vaccine
3. Influenza
4. DPT (diphtheria-pertussis-tetanus)
 Medications 2. Rh typing
1. Antibiotics other than anti-TB drugs (if medical condition is not severe) o Rh considerations for blood and components
2. Aspirin and piroxican – but not for platelets Single donor
Px Whole Donor plt Cryo
3. Contraceptive pills, depoprovera RBC Plasma full volume
type blood (Pheresed) ppt
4. Other drugs for symptomatic treatment platelets
+ +/- +/- +/- +/- +/- Irrel
- - - +/- - - Irrel
Types of Donation
 Directed Donation
o Potential recipient of blood or blood products designates certain   D Antigen
persons to donate specifically for his or her use  Most clinically significant of all non-ABO antigens
 Autologous Donation  Highly immunogenic
o When a person donates his or her own blood for personal use
o The blood is not to be used for anyone else
o If an autologous unit is collected but not used by the patient-donor, then
3. Crossmatching
it is destroyed.
o Types:
 Major crossmatch = Donor’s cells + Recipient’s serum
Republic Act 7719: National Blood Services Act of 1994
 Minor crossmatch = Donor’s serum + Recipient’s cells
 An act promoting voluntary blood donation, providing for an adequate
o Purpose:
supply of safe blood, regulating blood banks and providing penalties for
 Final check of ABO compatibility to prevent transfusionreaction
violations thereof
 Detect presence of antibody in patient’s serum that will react to
o Philippines annual blood requirement = 700 000 to 750 000 units
donor’s RBC that is not detected in antibody screen
o Target = 1% of the population
 Commercial blood banks are prohibited because:
4. Screening for blood group antibodies
o Blood sources may be contaminated
o Purpose: to detect as many “clinically significant antibodies” as possible
o Limited means of crosschecking donors
 Clinically significant Abs
 That may change names
~ Reactive at 37⁰C and/or in the AHG test
 That conceal their medical history
~ Known to have caused a transfusion reaction or
 That supply blood repeatedly
unacceptablyshort survival of the transfused red cell

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5. Serologic test to syphilis 7. Serologic tests for hepatitis: HbsAg, Hepatitis C antibody
o Non treponemal methods o Acute HBV Infection with Recovery: Typical Serologic Course
a. Venereal Disease Research Laboratory (VDRL) Test
b. Rapid Plasma Reagin (RPR)
o Treponemal methods
a. T. Pallidum Immobilization Test (TPI)
b. Fluorescent Treponemal Antibody Absorption Test (FTA- ABS)
c. T. Pallidum Hemagglutination Test (TPHA)
d. Microhemagglutination T. Pallidum Test (MHA-TP)

6. Serologic test for HIV: HIV antibody and HIV p24 antigen
o Human Immunodeficiency Virus (HIV)
 1982 = first cases od AIDS obtained from blood or blood products
were reported
 1983 = changes occurred in the donor criteria to exclude those at
high risk for transmission of HIV
 HIV markers during early infection

 Hepatitis B window period

~ HBV-DNA 31 days
~ HbsAg 56 days
~ ALT 78 days
~ Anti HBc 82 days

Hepatitis B Markers
Marker Significance
HBs Ag Best indicator of early acute infection
HBc Ag Found within the core of intact virus
Found only in infected liver tissues
HBe Ag Indicates chronic hepatitis
Reliable marker for the presence of high levels of virus
and high degree of infectivity
Anti-HBs Bestows lifetime immunity to further HBV infection
Anti-HBc Only marker seen during the window period
Anti-HBe First serologic evidence of convalescent phase
~ HIV RNA Day 11
~ HIV p24 Ag Day 16
~ HIV Ab Day 22

o Hepatitis C
 Clinical course of HIV
 Parenteral transmission, community acquired
 Mean incubation time: 6 to 8 weeks
 Hepatitis C markers during early infection

 
 
 
 
 
~ HCV RNA Day 12
 
~ Anti-HCV Day 70

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INDICATIONS FOR TRANSFUSION
STORAGE
WHOLE BLOOD
Approximate volume: 500 mL
Storage temperature: 1 - 6 ⁰C
Shelf life: 35- 42 days
Components: RBCs and plasma
Length of transfusion: 2-4hrs
 within 4 hrs after leaving the
blood bank
PACKED RED BLOOD CELLS
Approx volume: 225 - 250 mL
Storage temperature: 1 - 6 ⁰C
Shelf life: 35- 42 days
Length of transfusion: 2-4hrs
 within 4 hrs after leaving the
blood bank
WASHED RBC / LEUKOCYTE-POOR RBC
Approximate volume: 180mL
Storage temperature: 1 - 6 ⁰C
Shelf life: 24 hours after wash
 Wash= removes 70-80% of WBC
 Ffilter = removes 99% of WBC
IRRADIATED RBC
Shelf life: 28 days or the normal
dating period of blood
(whichever comes first)
Irradiation: Cs 137 or Co 60
PLATELET CONCENTRATE
Approximate volume: 50 mL
Storage temperature: 20 - 24 ⁰C
Shelf life: 5 days
 Requires continuous agitation
Length of transfusion: 30 mins
 within 4 hrs after leaving the
blood bank
FRESH FROZEN PLASMA
Approx volume: 200 - 250 mL
Storage temperature: ≤ -18 ⁰C
Shelf life: 1 year
Contains all coagulation factors with Reversal of coumadin anticoagulation
complement
Length of transfusion: 30 mins
 within 4 hrs after leaving the
blood bank
CRYOPRECIPITATE
Approximate volume: 15 - 20 mL
Storage temperature: ≤ -18 ⁰C
Shelf life: 1 year
Thawing: 20 - 24 ⁰C
Length of transfusion: 30 mins
 w/in 4 hrs after leaving the BB
INDICATIONS
ADULT PEDIATRIC
Active bleeding with at least one of the following: For exchange transfusion
 >15% blood volume loss  Hyperbilirubinemia – Direct bilirubin of 20 mg/dL
 Hb < 9 mg/dL during the 1st week of life
 Blood pressure decrease > 20%  Hyperbilirubinemia with prematurity or other
Systolic pressure < 90 mmHg concomitant illness:
o Prenatal asphyxia ᴏ Hypothermia
 When both oxygen-carrying capacity and volume o Acidosis ᴏ Sepsis
expansion are required o Prolonged hypoxemia ᴏ Hemolysis
Hb < 8 mg/dL or Hct < 24% Hypovolemia from acute blood loss
 Concomitant hemorrhage, COPD, CAD, sepsis,  Signs of shock
hemoglobinopathy  Anticipated blood loss of <10%
 General anesthesia
Hct < 30% (Nocturnal Hct < 35%)
Hb < 10 mg/dL or Hct < 30%  Major surgery
 Major operation
Anemia
Normovolemic patients (chronic anemia/ bleeding)  Chronic hemolytic anemia
who require an increase in oxygen-carrying  Anemia with Hb < 8 mg/dL or Hct < 25%
capacity and red cell mass regardless of Hb level  Signs and symptoms of anemia
Anemia with history of febrile reactions
Multiple transfusions
O blood for emergencies
Paroxysmal Nocturnal Hemoglobinuria (PNH)
Gravt versus host reactions Congenital immunodeficiency syndrome
Bone marrow transplant Fetus receiving intrauterine transfusion
Direct donation from a blood relative Exchange transfusion
 Prevents CMV reactions
Prophylaxis with platelet count ≤ 20 000/L Active thrombocytopenia
Hemolytic Uremic Syndrome (HUS)  Platelet count < 50 000/L
Plt count ≤ 50 000/L  Risk for intracranial hemorrhage
 Active bleeding
 Invasive procedure within 8 hrs Active bleeding and qualitative platelet defect
Plt count ≤ 100 000/L
 Surgery in critical area (eye, brain)
Massive transfusion with diffuse microvascular
bleeding and no time to obtain platelet count
Multiple coagulation deficiencies or acquired factor deficiency (Eg. Dengue shock syndrome)
PT or PTT > 1.5 times mid normal range within 8 hrs Significant congenital factor deficiency
of transfusion (PT > 17 secs; PTT > 47 secs) Anti thrombin III deficiency
Bleeding in exchange transfusion or massive
Treatment of TTP transfusion
Clinical coagulopathy associated with:
 Massive transfusion ≥ 10 U / 24 hours
 Late pregnancy
 Abruptio placentae
Preferred replacement for plasma exchange in TTP or HUS
Significant hypofibrinogenemia (Factor XIII): < 100 mg/dL
Hemophilia A
Von Willebrand’s Disease
Uremic bleeding with prolonged bleeding time
Burn or traumatic shock patients who lack fibronectin
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Administration Considerations 2. Extravascular
1. Platelets  Occurs outside the circulatory system (reticuloendothelial cells)
o Contraindications:  Most commonly involves the antibodies of the Rh system
a. Prophylactic transfusion in a stable patient with platelet  May not occur until a week or more after the transfusion
refractoriness of a known cause  Much milder than those of intravascular hemolysis
b. Thrombotic Thrombocytopenic Purpura (TTP) ~ Include malaise, fever, decreased hemoglobin
c. Idiopathic Thrombocytopenic Purpura (ITP)  Coomb’s test and hyperbilirubinemia
d. Heparin-induced Thrombocytopenia  Febrile Non-hemolytic Reactions
o Effect of platelet product and patient weight on platelet increment o Most common type of transfusion reaction
Patient wt Single whole blood Standard apheresis o Caused by sensitization to white cell, platelet or plasma antigens,
(in lbs) platelet concentrate especially in people who have received multiple transfusions
50 17 600 70 400 o Signs and symptoms:
100 8 800 35 200 1. Chills followed by fever within an hour after starting the transfusion
150 5 900 23 500 2. Headache
200 4 400 17 600 3. Nausea and vomiting
o Administration 4. Back or leg pain
a. Must not be refrigerated o Mgt: Use of leukocyte filters during transfusion; Anti pyretics
b. Require immediate transfusion  Allergic Reactions
c. Rate of infusion (10mL/min in adults) o Mediated by IgE
2. Fresh Frozen Plasma o Sx: Hives, rash and pruritus that may progress to laryngeal edema and
o General guidelines bronchial spasm
a. Document PT/PTT pre and post transfusion within 4 hours o Mgt: Administration of antihistamine before transfusion
b. Dose: 10 mL/kg BW or initial loading dose of 15 mL/kg BW  Anaphylactic Reactions
c. Correction of significant coagulopathy: o Potentially fatal
~ Prolonged PT and aPTT required > 2 units of FFP o Usually occur in people with antibodies against IgA immunoglobulins
o Administration o Signs and symptoms:
a. Must not be refrigerated 1. Generalized flushing
b. If transfusion cannot proceed immediately, return the unit to the BB 2. Dyspnea
for proper storage within 1 hour from release 3. Bronchospasm
3. General 4. Substernal pain
o Medications 5. Laryngeal edema and collapse
a. Do not add medications directly to a unit of blood during transfusion 6. Gastrointestinal distress (nausea and vomiting)
b. Medications by IV push  Circulatory Overload
~ Stop transfusion prior to administration of meds via IV o Develops in people with cardiac or renal impairment
~ Clear the line at the medical injection site with 5-10 mL NSS o Overload capacity of heart  circulatory failure  pulmonary edema
~ Administer the medication o Signs and symptoms:
~ Re-flush the line with saline 1. Dry cough  Productive cough
~ Restart the transfusion 2. Precordial and back pain
o Suspected transfusion reaction 3. Dyspnea
a. Stop the transfusion immediately 4. Cyanosis
b. Disconnect the IV line from the needle.  Infectious Diseases
c. Attach a new IV set and prime with saline. Flush the line with NSS o Transmission of diseases such as hepatitis, malaria, syphilis,
used to initiate the transfusion and reconnect the line. toxoplasmosis and AIDS
d. Open the line to slow drip.  Graft vs Host Disease
e. It may be possible to restart transfusion after evaluation and o Occurs when immunocompetent donor lymphocytes (commonly found
treatment of the patient. in PRBC and granulocytes) are transfused and multiply in severely
immunodeficient recipients
COMPLICATIONS OF TRANSFUSION  Bacterial Contamination (Eg. Pseudomonas and coliforms)
o Cause: improper preparation of donor phlebotomy site or inadequate
 Hemolytic Transfusion Reactions refrigeration
1. Intravascular  Air Embolism
 Due to immune mechanism; mediated by IgM and complement o Introduction of air into the circulation
 Signs and symptoms: o Sx: cyanosis and circulatory collapse
a. Anxiety e. Tachypnea  Citrate Intoxication
b. Restlessness f. Tachycardia o When toxic levels of citrate is reached  Depression of blood calcium
c. Nausea and vomiting g. Chills followed by fever  Muscle twitching and spasm  Possible cardiac arrest
d. Chest or lumbar pain h. Cyanosis  Hemorrhagic Reaction
 Causes: o Since refrigeration destroys platelets, stored blood is low in viable
a. ABO incompatibility (misID of patient or blood) platelts
b. Antibodies other than anti-A or anti-B
c. Exposure of red cells to hypertonic solutions Quality trans brought to you by:
d. Improper storage of blood PATHO TEAM

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