TRANSFUSION MEDICINE: COMPONENT THERAPY

At the end of this unit, the learners must be able to:

1. differentiate the various components as to the manner
of preparation, storage and indications.

A. Review of Terms
a. Massive blood transfusion
b. Multiple transfusions
c. Chronic transfusions
d. Autologous blood transfusion
e. Allogeneic blood transfusion
f. Voluntary non-remunerated blood donor
i. Directed donor
ii. Replacement donor
iii. Altruistic donor
g. Blood Derivatives/Blood Components
h. Apheresis
i. Intermittent flow centrifugation
ii. Continuous flow centrifugation
i. Therapeutic bleeding and therapeutic
plasma exchange
j. Universal donor & universal recipient
k. Blood substitutes
 B. Blood Components
Component Indication Storage (Temp in Content: Preparation & other
°C, Shelf Life) Composition, remarks
Volume, QA
Whole blood Volume expansion, 1-6, depends on 450-500 ml: Must be ABO & Rh
increase oxygen anticoagulant RBC (40%) compatible
Plasma Inc Hgb 1g/dL
Platelets Inc Hct by 3%
WBCs
Stored or transfused as
collected

Irradiated WB Volume expansion, 1-6, depends on 450-500 ml: Must be ABO & Rh
increase oxygen in anticoagulant RBC (40%) compatible
patients at risk to TA- Plasma Inc Hgb 1g/dL
GVHD & FNHTR 28 days from Platelets Inc Hct by 3%
irradiation
whichever comes 15-25 Gy (US, Phil)
first 25-50 Gy (New
Zealand, Australia)

Special labelling

RBCs Increase oxygen in 1-6, depends on 250-300 ml: Must be ABO & Rh
normovolemia or anticoagulant (if RBC (> or =80%) compatible
high risk of closed system) Plasma (</=20%) Inc Hgb 1g/dL
circulatory overload Additive solutions Inc Hct by 3%
24 hours (if open (optional)
system) - Toxicity Sedimentation or
- Cost centrifugation of FWB
- Allergies (8-24 hrs)

RBC irradiated Increase oxygen in 1-6, depends on 250-300 ml: 15-25 Gy (US, Phil)
normovolemia or anticoagulant RBC (< or =80%) 25-50 Gy (New
high risk of Plasma (>/=20%) Zealand, Australia)
circulatory overload 28 days from
and/or TA-GVHD & irradiation
FNHTR whichever comes
first

RBC aliquots Increase oxygen in 1-6, 24 hours in Volume varies (usu Must be ABO & Rh
neonates/infants CPD-A1 10-25 ml) compatible (10ml/Kg
in a unit)
Inc Hgb 1g/dL
Inc Hct by 3%

Syringe or Pedi-Pak

RBC Increase oxygen in 1-6, depends on 250-300 ml Must be ABO & Rh

leukoreduced patients prone to anticoagulant (if -same as RBCs- compatible
 FNHTR closed system) <5 x 106 WBCs Inc Hgb 1g/dL
Prevent TRALI, EBV, 24 hours (if open) >/= 85% RBC Inc Hct by 3%
CMV & HTLV trans recovery
Sedimentation or
centrifugation of FWB
(8-24 hrs)

Some cases of
hypotension/allergic
reaction

Washed RBCs Washed – for PNH, Up to 10 years Washed (180 ml): Must be ABO & Rh
(and IgA deficiency when frozen at - 70-80% RBC compatible
deglycerolized Frozen – rare 65, 24 hours when <5 x 108 WBC Inc Hgb 1g/dL
RBCs) phenotype, washed, 1-6 Deglycerolized Inc Hct by 3%
autologous, military (180 ml):
inventory <300 mg Hgb
<1% glycerol
80% RBC
Saline
Dextrose <1%
WBC, platelets

Platelets (RD) Thrombocytopenia, 20-24, 5 days with 50-70 ml: Increases platelet by
DIC, bleeding agitation Platelets >/= 5.5 x 5-10k/microliter
1010, pH 6.2 Prepared from WB
Pooled: 4 hours 40 to 70 ml plasma within 4 hrs of
8.3 x 105 WBC collection
Coagulation
factors No crossmatching
required

Type specific

Platelets (SD) Thrombocytopenia, 20-24, 5 days with 200-400 ml: Through apheresis
DIC, bleeding to agitation Platelets >/= 3 x Increases platelet by
limit HLA 1011 30-60K/microliter
alloimmunization & 300 ml of plasma
limit exposure pH 6.2 HLA compatible
Platelet coagulation
refractoriness factors

Platelet Neonates with 20-24, 5 days with 5 to 10 ml Increases platelets by

aliquots <50,000/microliter agitation 50,000 to 100,000 per
5-10ml/Kg

Platelets Thrombocytopenia, 20-24, 5 days with 200-400 ml: HLA compatible

(irradiated) DIC, bleeding in agitation Platelets >/= 3 x
patients prone to 1011
TA-GVHD 300 ml of plasma
pH 6.2
coagulation
 factors

Platelets Thrombocytopenia, -same- Platelets >/= 5.5 x SD: HLA

(leukoreduced) DIC, bleeding in 1010, pH 6.2
patients prone to 40 to 70 ml plasma
FNHTR 5 x 105 WBC
Coagulation
factors

FFP Replacement of all -18 for 1 year Stable and labile Prepared from WB
PF24 coagulation -65 for 7 years factors 1 IU/ml within 24 hrs of
factors/multiple collection then frozen
coagulation factor Thawed, use within 6 (ACD) to 8
deficiency within 24 hours, if (CDP, CD2D, CPD-A1)
Actively bleeding not can be stored hours
Reversal of warfarin 1-6 after thawing
TTP up to 5 days
including initial 24
(reduced
amounts of V, VII,
VIII & X)
Cryoprecipitate Fibrin glue -18, 1 year Factor VIII (80 units WB CPD or CPD-A1,
manufacturing 20-24 or Thawed, of AHF) frozen, thawed to a
Hemophilia A 6 hours Fibrinogen (150 slurry at 1-6,
VWD FXIII deficiency Pooled: 4 hrs mg) centrifuged
Hypofibrinogenemia Factor XIII, von Increases fibrinogen by
Willebrand 5-10 mg/dL
Fibronectin ABO compatible
15-25 ml of plasma
Cryo-poor Plasma exchange -18 or colder Albumin, factors II, Prepared from FFP
plasma/plasma for TTP 1year V, VII, IX, X, XI and after thawing &
cryo-reduced Source of specific ADAMTS13 obtaining
factors cryoprecipitate, frozen
within 24 hours
COMPATIBILITY TESTING

At the end of this unit, the learners must be able to:

1. classify and explain the different crossmatching
procedures;
2. apply learned concepts to resolution of
incompatible crossmatches;
3. master the techniques of the major and minor
crossmatches;
4. analyze the applications of other laboratory tests;
and
5. understand the present and future trends in
blood banking automation.

A. Limitations
a. Cannot guarantee RBC viability
b. Cannot totally eliminate transfusion
reactions

B. Pre-transfusion testing
a. ID, collection & prep of samples
i. Donor sample:
1. By collecting facility: ABO & Rh
grouping, disease transmission,
antibody ID if w/ possible sensi.
2. By transfusing facility: confirm ABO &
Rh using attached segment
ii. Patient sample:
1. ABO & Rh, antibody screening
 b. Selection of donor units:
i. Crossmatch

C. Importance of Serologic Crossmatch:

a. Final ABO compatibility check
b. Antibody against untested Ag
c. Can be eliminated if (a.k.a. Type & Screen):
i. No clinically significant antibodies were
detected in the antibody screening
process
ii. No detection of clinically significant
unexpected antibodies

STEP REAGENT PURPOSE OF CLINICAL

REAGENT SIGNIFICANCE

SALINE – ROOM NSS - IgMs, cold -most ABO

TEMPERATURE agglutinins & incompatibilites
wide thermal
range abs

SALINE - 37° C NSS/LISS -detection of - Potent Rh antibodies

IgG antibodies,
potentiator
ALBUMIN OR 22% BSA -reduce zeta -increases strength of
HIGH PROTEIN potential immediate spin
TEST between RBCs agglutination

ANTIGLOBULIN AHG - Detect IgG -Identify patients who

PHASE and C’ bound demonstrate clinically
to RBC important Ab...
membrane

D. Computer Crossmatch
E. Emergency Crossmatch
a. Abbreviated
b. Incomplete crossmatch

POLYAGGLUTINATION

At the end of this unit, the learners must be able to:

1. understand the present and future trends in blood
banking automation.

A. Definition
a. Red cells that are agglutinated by a large
proportion of adult human sera regardless of
blood group.
b. Usually non-reactive with autologous serum
B. Classification
a. Acquired/Microbial associated (Transient,
common)
▪ T, Tk, Acquired-B, Th, VA
b. Inherited/Non-microbial associated
(permanent & irreversible)
• Tn, CAD, NOR
• HEMPAS (hereditary erythroblastic
multinuclearity w/ a positive acidified
serum) a chronic dyserythropoietic anemia

C. Laboratory testing
a. Detection
i. Not easily detected
1. Natural polyagglutinins are destroyed
during the manufacturing process
2. Antibodies are low in titer
3. Apparent during crossmatching (esp
minor)
b. Confirmation and classification
i. RBC should be tested with several cord
blood sera and with several normal group
AB adult sera
ii. Enzymes and Sulfhydril compounds
iii. Lectins
iv. Adsorption and elution
v. Aged sera
vi. Dilution

D. Clinical Significance
a. Hemolytic anemia & HTR
 b. Hemolytic uremic syndrome
c. Breast cancer and other malignancies
d. Leukemia

ADVERSE EFFECTS OF BT

At the end of this unit, the learners must be able to:

1. enumerate and discuss the common types of
transfusion reactions;
2. apply the basic principles of laboratory tests in
analyzing cases regarding transfusion reactions;

A. Classifications
a. Acute/Immediate vs delayed
b. Immunologic vs. Non-immunologic
c. Infectious/TTI/TTD vs. non-infectious
• Immediate (24hrs) • Delayed
– Immunologic – Immunologic
• IHTR • EHTR
• FNHTR • TA-GVHD
• Allergic or • PTP
urticarial – Non-immunologic
• Anaphylactic • Hemosiderosis
• TRALI • Dse transmission
– Non-immuno-logic
• Bacterial
contamination
• TACO
• Physical or
chemical
hemolysis

Acute Transfusion Reactions

Febrile Allergic Pulmonary
AHTR TAS FNHTR Mild Severe TACO TRALI

Delayed Transfusion Reactions

Serological hemolytic TAGVHD PTP iron Overload

B. Risk management of adverse reactions

a. Pathogen inactivation
b. Proper donor screening
c. Proper blood utilization
 C. Assignment – complete table below:
Reaction S&S Cause Work-up Management
(Treatment &
Prevention)
AHTR Pain: abdomen, Naturally DAT (+) Follow SOP
(immune- chest, flank, back, occurring or L Hgb Discontinue
mediated) infusion site previously H LDH transfusion
Feeling of formed Abs H Bilirubin Maintain IV & BP
impending doom against L haptoglobin Treat DIC if present
Hemoglobinuria donor Ag’s
Hemoglobinemia
Hypotension
Renal failure
Shock
DIC

Fever/chills
AHTR (non- asymptomatic Chemical or DAT (-) Follow SOP
immune) hemoglobinuria mechanical Maintain IV & BP
renal dysfunction damage Maintain renal
blood flow
Discontinue
transfusion
Clerical
verification
Notify physician

Trans- Fever/chills (=/> Bacterial DAT (-) Discontinue

associated 2ºC) contam GS blood bag transfusion
sepsis Rigor Culture bag Maintain vascular
Hypotension Culture patient access
Shock Consider antibiotic
Follow SOP
Implement
bacterial
detection
intervention
A. Transfusion-Transmitted/Associated Diseases
a. Viruses:
i. Hepatitis (A, B, C, D, E, G)
ii. HIV Types 1 and 2
iii. HTLV I and II
iv. West Nile Virus
v. CMV
vi. EBV
vii. Parvovirus B19
viii. Human Herpesvirus 6 and 8
b. Bacteria
i. Syphilis
ii. Tick-borne bacterial agents
 c. Parasites
i. Babesia microti
ii. Trypanosoma cruzi
iii. Malaria
d. Prion
i. Creutzfeld-jakob disease

OTHER TESTS FOR ANTIBODY DETECTION

At the end of this unit, the learners must be able to:

1. apply the basic principles of laboratory tests in
analyzing cases regarding transfusion
reactions;

A. Neutralization/Hemeagglutination inhibition
B. Adsorption and elution
C. Antibody screening
MEDICO-LEGAL ASPECTS OF BB

At the end of this unit, the learners must be able to:

1. learn the ethical implications and considerations
in transfusion medicine.

A. Civil lawsuits:
1. Striking or threatening to strike another person
(battery and assault)
• Intentional infliction of emotional distress
• Invasion of privacy under civil case law

2. Being careless or reckless (negligence)

• A duty was owed to the injured party
• Duty was not met by the injuring party
• Injured party was harmed
• Failure to meet the duty owed was directly
responsible for or could have been
predicted to cause the harm suffered by
the injured party.
• Some measurable (compensable) harm
(called “damages”) occurred.

3. Failing to complete an agreement (breach of

contract)
 4. Intruding on another’s property or privacy

5. Misbehaving on other similar ways

B. Governing laws and policies

1. Doctrine of informed consent
2. Standard of care (professional & ordinary)
• Is the treatment the best course of
treatment? Did the professional do
everything possible to avoid
consequences? Are there alternatives?
(note: blood pharming, blood alternatives)
• Examples of adverse donor reactions:
• Systemic reactions (dizziness, sweating,
nausea, vomiting, weakness,
apprehension, pallor, hypotension,
bradycardia, syncope, convulsions)
NB: pulse rate is usually high during
volume depletion & low during
vasovagal reactions
o Common among young, low-
weight, female, first-time
• Bruise or hematoma
• Fatigue
• Local nerve injury
• Arterial puncture
 • Upper extremity deep vein thrombosis
• Postdonation mortality
3. Respondeat superior
4. Statutes of limitation
5. Risk management/reduction
• Screening & voluntary donation
• Untimely notification
• Component collection, processing
• Proper documentation & endorsement
• Quality control
6. Ethics:
• Principles: Autonomy, Beneficence, Justice
• Issues:
• Feelings of rejection when deferred as
donor
• Confrontation of old diseases
(diseases that they feel cured of or
they have already forgotten about)
• Confrontation with unrealized risks
• Feelings of discrimination
• Conflicting guidelines on deferral
• Cases when anonymity is not possible
(stem cell or HLA specific transfusions)
• Recently diseased persons as blood
donors

7. Morals vs. righteousness

REFERENCES:

A. Textbook:
a. Harmening, Denise M. Modern Blood Banking and Transfusion Practices (2012). 6th
Edition. F.A. Davis Company.

B. Reference Books:
a. Blaney, Kathy D and Howard, Paula R. Basic and Applied Concepts of
Immunohematology (2008). 2nd Edition. Mosby, Inc. .
b. AABB Committee (2011). Standards of Blood Banks and Transfusion Services. 27th
Edition. USA: American Association of Blood Banks.
c. Fung, Mark K; Grossman, Brenda J; Hillyer, Christopher D; and Westhoff, Connie M
(2014). 18th Edition. Technical Manual (AABB). Maryland, USA.
d. Mcpherson, Richard A. and Pincus, Matthew (2017). Henry’s Clinical Diagnosis and
Management by Laboratory Methods. 23rd Edition. Philadelphia: Elsevier Inc.

C. Related Websites and other materials:

a. American Association of Blood Banks. Available at:
http://www.aabb.org/Pages/Homepage.aspx. Accessed on November 6, 2017.
b. American Red Cross. Available at http://www.redcross.org/ Accessed on November 6,
2017.
c. Department of Health. Available at http://www.doh.gov.ph Accessed on November 6,
2017.
d. Human Blood. Available at http://www.fi.edu/learn/heart/blood/blood.html. Accessed on
November 6, 2017.
e. Hematology-Blood Bank Links to Related Sites. Available at
http://www.lhsc.on.ca/lab/bldbank/links.htm. Accessed on November 6, 2017.
f. International Society of Blood Transfusion. Available at http://www.isbtweb.org/.
Accessed on November 6, 2017.
g. Medical Laboratory Observer. Available at http://www.mlo-online.com. Accessed on
November 6, 2017.
h. World Health Organization. Available at http://www.who.int/en/. Accessed on November
6, 2017.

Note:

Regarding the pictures presented in this document, these fall into one of the
following types: photographs personally taken by the document’s author,
downloaded from the internet under creative commons license, or
scanned/downloaded from the references listed; unless otherwise stated in the
photograph or caption.

Prepared by: CRIZELDA L. SALITA, MS, RMT