2.
Essential that all blood is tested before transfusion:
Ensure that transfused red cells are compatible with
antibodies in the recipient’s plasma
Avoid stimulating the production of new red cell
antibodies in the recipient, particularly anti-RhD.
LAB TEST
3.
All pre-transfusion test procedures should provide
the following information about both the units of
blood and the patient:
ABO group
RhD type
Presence of red cell antibodies that could cause
haemolysis in the recipient
Infective screening
LAB TEST
5.
Blood grouping methods:
Tube method
Gel method
Forward grouping: using known anti-A, Anti-B, Anti-AB
antisera
Reverse grouping: using known A1 cells, B cells and O cells.
Infants less than 4 months old do not require reverse grouping.
In a life threatening situation, group O packed red cells may be
issued.
ABO Blood Group
6.
A single unit of RhD positive red cells transfused to
an RhD negative person will usually provoke
production of anti-RhD antibody.
This can cause:
Haemolytic disease of the newborn in a subsequent
pregnancy
Rapid destruction of a later transfusion of RhD
positive red cells.
2. RhD
7.
Rh D grouping: using Monoclonal IgM/IgG blend antisera
by one of the following methods
Tube method
Gel method
recommended that Rh D should be tested in duplicate with
two IgM/IgG blend monoclonal anti-D blood-grouping
reagents, with one which should not detect D VI .
Rh D negative patients should be phenotyped for C, c, E & e
antigens.
RhD
8.
Detecting clinically significant red cell antibodies
reactive by hemolysis and/or haemagglutination at
room temperature, 37°C.
Include a 37°C incubation phase and an indirect
antiglobulin test.
3. Antibody Screening
9.
If screening test is positive and/or incompatible cross-
match detected, antibody identification should be
performed
using a reagent red cell panel that covers all the significant
antigens.
should be able to demonstrate the presence of antibody
Provide blood that is negative for the corresponding
antigen
lead to more samples needed and a considerable delay
potential risk of adverse reactions must be balanced with
the risk of delaying the transfusion
4. Antibody Identification
10.
Crossmatch
patient's serum is tested directly for compatibility with the
red cells of the units of blood to be transfused
after ABO and Rh D determination
with or without antibody screening
carried out at room temperature, 37°C and with antihuman
globulin (AHG/IAT) phase.
If clinically significant antibodies are present or where
there is history of clinically significant antibodies, antigen
negative blood should be cross matched until AHG/IAT
phase.
5. COMPATIBILITY TESTING
11.
Screening of all blood donations should be mandatory for
the following infections and using the following markers:
HIV-1 and HIV-2: screening for either a combination of HIV
antigen-antibody or HIV antibodies
Hepatitis B: screening for hepatitis B surface antigen
(HBsAg)
Hepatitis C: screening for either a combination of HCV
antigenantibody or HCV antibodies
Syphilis (Treponema pallidum): screening for specific
treponemal antibodies.
6. Infective Screening
12.
Any therapeutic substance prepared from human blood
Whole blood
Unseparated blood collected into an approved container
containing an anticoagulant-preservative solution
Blood component
A constituent of blood, separated from whole blood
Plasma derivative
Human plasma proteins prepared under pharmaceutical
manufacturing conditions
BLOOD PRODUCTS
13. Up to 510 ml total volume (volume may vary in accordance with local policies)
450 ml donor blood
63 ml anticoagulant-preservative solution
Haemoglobin approximately 12 g/ml
Haematocrit 35%–45%
No functional platelets
No labile coagulation factors (V and VIII)
1. Whole Blood
Indication
Red cell replacement in acute blood loss with hypovolaemia
Exchange transfusion
Patients needing red cell transfusions where red cell
concentrates or suspensions are not available
14.
a) RED CELL CONCENTRATE
(‘Packed red cells’, ‘plasma-reduced blood’)
150–200 ml red cells from which most of the plasma has been
removed
Haemoglobin approximately 20 g/100 ml (not less than 45 g per
unit)
Haematocrit 55%–75%
2. Blood Components
Indication
Replacement of red cells in anaemic patients
Use with crystalloid replacement fluids or colloid solution
in acute blood loss
15.
b) RED CELL SUSPENSION
150–200 ml red cells with minimal residual plasma to which ±100
ml normal saline, adenine, glucose, mannitol solution (SAG-M) or
an equivalent red cell nutrient solution has been added
Haemoglobin approximately 15 g/100 ml (not less than 45 g per
unit)
Haematocrit 50%–70%
Blood Components
Indication
Replacement of red cells in anaemic patients
Use with crystalloid replacement fluids or colloid
solution in acute blood loss
16.
c) LEUCOCYTE-DEPLETED RED CELLS
A red cell suspension or concentrate containing <5 x 106
white cells per pack
Prepared by filtration through a leucocyte-depleting filter
Haemoglobin concentration & haematocrit depend on
whether the product is whole blood, red cell concentrate or
red cell suspension
Leucocyte depletion significantly reduces the risk of
transmission of cytomegalovirus (CMV)
Blood Components
17.
c) LEUCOCYTE-DEPLETED RED CELLS
Blood Components
Indication
Minimizes white cell immunization in patients receiving
repeated transfusions but, to achieve this, all blood
components given to the patient must be leucocyte-
depleted
Reduces risk of CMV transmission in special situations
Patients who have experienced two or more previous
febrile reactions to red cell transfusion
18.
d) PLATELET CONCENTRATES
(prepared from whole blood donations)
Single donor unit in a volume of 50–60 ml of plasma contain:
At least 55 x 109 platelets
<1.2 x 109 red cells
<0.12 x 109 leucocytes
Blood Components
Indication
Treatment of bleeding due to:
Thrombocytopenia
Platelet function defects
Prevention of bleeding due to thrombocytopenia, such as
in bone marrow failure
19.
e) PLATELET CONCENTRATES
(collected by plateletpheresis)
Volume 150–300 ml
Platelet content 150–500 x 109, equivalent to 3–10 single
donations
Platelet content, volume of plasma and leucocyte
contamination depend on the collection procedure
Blood Components
Indication
Generally equivalent to the same dose of platelet
concentrates prepared from whole blood
If a specially typed, compatible donor is required for the
patient, several doses may be obtained from the selected
donor
20. f) FRESH FROZEN PLASMA
plasma separated from one whole blood donation within 6 hours
of collection and then rapidly frozen to –25°C or colder
normal plasma levels of stable clotting factors, albumin and
immunoglobulin
Factor VIII level at least 70% of normal fresh plasma level
Blood Components
Indication
Replacement of multiple coagulation factor deficiencies:
Liver disease
Warfarin (anticoagulant) overdose
Depletion of coagulation factors in patients receiving large
volume transfusions
Disseminated intravascular coagulation (DIC)
Thrombotic thrombocytopenic purpura (TTP)
21.
g) LIQUID PLASMA
Plasma separated from a whole blood unit and stored at +4°C
No labile coagulation factors (Factors V and VIII)
h) CRYOPRECIPITATE-DEPLETED PLASMA
Plasma from which approximately half the fibrinogen and Factor
VIII has been removed as cryoprecipitate, but which contains all
the other plasma constituents
i) VIRUS ‘INACTIVATED’ PLASMA
Plasma treated with methylene blue/ultraviolet light inactivation
to reduce the risk of HIV, hepatitis B and hepatitis C
Cost is higher than conventional fresh frozen plasma
The ‘inactivation’ of other viruses, such as hepatitis A and human
parvovirus B19 is less effective
Blood Components
22.
j) CRYOPRECIPITATE
Prepared from fresh frozen plasma by collecting the precipitate formed during
controlled thawing at +4°C and resuspending it in 10–20 ml plasma
Contains about half of the Factor VIII and fibrinogen in the donated whole
blood: e.g. Factor VIII: 80–100 iu/ pack; fibrinogen: 150–300 mg/pack
Blood Components
Indication
Alternative to Factor VIII concentrate in the treatment of
inherited deficiencies of:
von Willebrand Factor (von Willebrand’s disease)
Factor VIII (haemophilia A)
Factor XIII
As a source of fibrinogen in acquired coagulopathies:
disseminated intravascular coagulation (DIC)
23.
a) HUMAN ALBUMIN SOLUTIONS
Prepared by fractionation of large pools of donated plasma
3. Plasma Derivatives
Indication
Replacement fluid in therapeutic plasma exchange:
use albumin 5%
Treatment of diuretic-resistant oedema in hypoproteinaemic
patients: e.g. nephrotic syndrome or ascites.
Use albumin 20% with a diuretic
Although 5% human albumin is currently licensed for a wide range of
indications (e.g. volume replacement, burns and hypoalbuminaemia),
there is no evidence that it is superior to saline solution or other
crystalloid replacement fluids for acute plasma volume replacement
24.
b) COAGULATION FACTORS
Factor VIII concentrate
Partially purified Factor VIII prepared from large pools
of donor plasma
Factor VIII ranges from 0.5–20 iu/mg of protein.
Preparations with a higher activity are available
Products that are licensed in certain countries (e.g. USA
and European Union) are all heated and/or chemically
treated to reduce the risk of transmission of viruses
Plasma Derivatives
25.
a) COAGULATION FACTORS
Factor VIII concentrate
Plasma Derivatives
Indication
Treatment of haemophilia A
Treatment of von Willebrand’s disease:
use only preparations that contain von Willebrand
Factor
26.
b) PLASMA DERIVATIVES CONTAINING FACTOR IX
Prothrombin complex concentrate (PCC)
Contains:
Factors II, IX and X
Some preparations also contain Factor VI
Factor IX concentrate
Contains:
Factors II, IX and X
Factor IX only
Plasma Derivatives
27.
Plasma Derivatives
Indication
Both Prothrombin complex concentrate (PCC) & Factor
IX concentrate:
Treatment of haemophilia B (Christmas disease)
PCC:
Immediate correction of prolonged prothrombin time
28.
c) COAGULATION FACTOR PRODUCTS FOR PATIENTS WITH
FACTOR VIII INHIBITORS
A heat-treated plasma fraction containing partly-activated
coagulation factors
Plasma Derivatives
Indication
Only for use in patients with inhibitors to Factor VIII
29.
d) IMMUNOGLOBULINS
Immunoglobulin for intramuscular use
Concentrated solution of the IgG antibody component of
plasma
Plasma Derivatives
Indication
Hyperimmune or specific immunoglobulin:
from patients with high levels of specific antibodies to infectious
agents: e.g. hepatitis B, rabies, tetanus
Prevention of specific infections
Treatment of immune deficiency states
30.
Immunoglobulin for intravenous use
As for intramuscular preparation, but with subsequent
processing to render product safe for IV administration
Plasma Derivatives
Indication
Idiopathic autoimmune thrombocytopenic purpura and
some other immune disorders
Treatment of immune deficiency states
Hypogammaglobulinaemia
HIV-related disease
31.
Anti-RhD immunoglobulin (Anti-D RhIG)
Prepared from plasma containing high levels of anti-RhD
antibody from previously immunized persons
Plasma Derivatives
Indication
Prevention of haemolytic disease of the newborn in
RhD negative mothers
32.
Ayob DDY, Haji Hassan DA, Yahya NM. Transfusion
Practice Guidelines For Clinical And Laboratory
Personnel [Internet]. National Blood Centre Ministry Of
Health Malaysia 3rd Edition 2008. 2008 [cited 2015 May
19]. Available from:
http://hsajb.moh.gov.my/versibaru/uploads/bloodban
k/garispanduan2.pdf
The Clinical Use of Blood [Internet]. World Health
Organization Blood Transfusion Safety GENEVA. [cited
2015 May 19]. Available from:
http://www.who.int/bloodsafety/clinical_use/en/Han
dbook_EN.pdf
References
Editor's Notes
These antibodies are usually of IgM and IgG class and are normally able to haemolyse (destroy) transfused red cells.
Tube method:
principle of agglutination.
Normal red blood cells, possessing antigens, will agglutinate in the presence of antibodies directed toward those antigens.
Commercial antisera are used to test patient and donor cells. Patient plasma/serum is then tested against reagent A1 and B red cells.
The ABO reaction should be reciprocal and does not require red cell stimulation.
Weakened expression of the RhD antigen The collective term Du is widely used to describe red cells which have a weaker expression of the D antigen than normal. The term weak D denotes individuals with a reduced number of complete D antigen sites per red cell. The term partial D denotes individuals with missing D antigen epitopes. DVI is a partial D category which misses most D epitopes. Blend reagent will detect most examples of partial and weak D red cells by direct agglutination, but will not detect DVI cells. This reagent will detect DVI and partial D cells in the IAT phase.
Reagent red cells shall consist of at least two group O red cells, NOT POOLED, and should express the following antigens: C, c, D, E, e, M, N, S, s, K, k, Fy a , Fy b , Jk a , Jk b . Where possible, one cell should be of the R1R1 phenotype (CDe phenotype) and the other of R2R2 phenotype (cDE phenotype). Additional antigens may be included to reflect the antigenic profile of the local population
Samples from patient to whom the crossmatched blood is transfused should be retained for at least 7 days post transfusion for the purpose of investigation of any reported transfusion reactions. 10.6.5 Once a transfusion has commenced, new sample is required for further transfusion. Sample should always accompanied by request form .However, if the second crossmatch gives an incompatible result eventhough specific antigen-negative group is given and similar to the previous transfusion, a re-investigation for antibody must be performed. 10.6.6 Units that have been crossmatched but not transfused within 48 hours shall be subjected to pretransfusion testing against a new sample from the patient.
Screening of donations for other infections, such as those causing malaria or Chagas disease, should be based on local epidemiological evidence.
4 Screening should be performed using highly sensitive and specific assays that have been specifically evaluated and validated for blood screening.
5 Quality-assured screening of all donations using serology should be in place before additional technologies such as nucleic acid testing are considered.
6 Only blood and blood components from donations that are nonreactive in all screening tests for all markers should be released for clinical or manufacturing use.
7 All screen reactive units should be clearly marked, removed from the quarantined stock and stored separately and securely until they are disposed of safely or kept for quality assurance or research purposes, in accordance with national policies.
Contraindications Will not prevent graft-vs-host disease: for this purpose, blood components should be irradiated where facilities are available (radiation dose: 25–30 Gy)
Alternative ■ Buffy coat-removed whole blood or red cell suspension is usually effective in avoiding febrile non-haemolytic transfusion reactions ■ The blood bank should express the buffy coat in a sterile environment immediately before transporting the blood to the bedside ■ Start the transfusion within 30 minutes of delivery and use a leucocyte filter, where possible ■ Complete transfusion within 4 hours of commencement
Contraindications ■ Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant pre-operative platelet deficiency ■ Not indicated in: — Idiopathic autoimmune thrombocytopenic purpura (ITP) — Thrombotic thrombocytopenic purpura (TTP) — Untreated disseminated intravascular coagulation (DIC) — Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism
Complications Febrile non-haemolytic and allergic urticarial reactions are not uncommon, especially in patients receiving multiple transfusions
Precautions ■ Acute allergic reactions are not uncommon, especially with rapid infusions ■ Severe life-threatening anaphylactic reactions occasionally occur ■ Hypovolaemia alone is not an indication for use
Precautions Administration of 20% albumin may cause acute expansion of intravascular volume with risk of pulmonary oedema Contraindications Do not use for IV nutrition: it is an expensive and inefficient source of essential amino acids
Alternatives ■ Cryoprecipitate, fresh frozen plasma ■ Factor VIII prepared in vitro using recombinant DNA methods is commercially available. It is clinically equivalent to Factor VIII derived from plasma and does not have the risk of transmitting pathogens derived from plasma donors
Contraindications PCC is not advised in patients with liver disease or thrombotic tendency