BLOOD COMPONENT PREPARATION AND TRANSFUSION THERAPY

Hemotherapy
• Use of blood components to treat a disease in a patient

Component therapy
• Transfusion of specific components (e.g., red blood cells, platelets, plasma) rather than whole blood to treat a
patient
• Components are separable by physical means such as centrifugation

Preparation of Blood Components

1. Centrifugation
o Heavy Spin
• 5000 g for 5 minutes: ____________________________________________
• 5000 g for 7 minutes: ____________________________________________

o Light Spin
• 2000 g for 3 minutes: ____________________________________________

Note:
• For preparation of platelet concentrate, centrifugation is performed at __________
• For all other blood components, centrifugation is carried out between __________

2. Sedimentation

3. Leukocyte reduction

4. Washing

5. Apheresis
o A method of blood collection in which whole blood is withdrawn, a desired component separated and retained,
and the remainder of the blood returned to the donor
o Types:
• Erythrocytapheresis • Leukapheresis
• Plateletpheresis or thrombocytapheresis • Plasmapheresis

6. Irradiation
o Gamma or electron treatment of a cellular blood product

7. Recombinant DNA technology

o A process of recombining two DNA fragments from different species and inserting such recombinant molecule
into a host organism in order to produce new genetic combinations that are of value in medicine, science, and
industry

Note: Open and Close System

System Explanation Effect on Expiration Date of Component
Open System o Seal on unit is broken to attach external o Components stored at 1°to 6°C must be
transfer bag used within _____ hours after system
o Exposure to air poses threat of bacterial opened
contamination o Components stored at 20° to 24°C within
_____ hours
Close System o Sterility maintained through use of attached o No change
satellite bags or sterile connecting device
that welds tubing from 1 bag to another
o No exposure to air

Transfusion Therapy
A. Whole Blood
Whole Blood
o Provide blood volume expansion and RBC mass in acute blood loss; for actively bleeding
Indication: patients who have lost at least 25% of their blood volume, or patients requiring exchange
transfusions
Storage:
Transport:
Shelf Life:
o When whole blood is not available, reconstitute whole blood by mixing RBCs with thawed
Others:
AB type plasma from a different donor

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B. Blood Components
1. Red Blood Cells
• Indications:
o Decreased oxygen-carrying capacity or acute loss of more than 20% blood volume or hemoglobin less
than __________ or hematocrit less than __________
• Exceptions:
o Patients with hemoglobin less than 8 g/dL and acute coronary syndrome
• Outcomes:
o Check hemoglobin and hematocrit less than 24 hours after transfusion
o 1 unit of Whole Blood or 1 unit of Packed RBC can
• ↑ hemoglobin by __________
• ↑ hematocrit by __________
o Surgical patients: postoperative hemoglobin less than preoperative hemoglobin

Packed RBCs
o 80% of plasma removed from whole blood
Preparation:
o Hematocrit: ____________________
o Indication of RBC mass of symptomatic, normovolemic patients
Indication: o For oncology patients undergoing chemotherapy or radiation therapy, trauma patients,
dialysis patients, premature infants and patients with sickle cell anemia
Storage:
Transport:
o Open system
Shelf Life:
o Close system

Leukocyte-reduced RBCs
o Filtration (within __________ from time of collection) or apheresis; saline washing
Preparation:
o Must retain 85% of original RBCs
o Increase RBC mass in patients with severe and/or recurrent febrile transfusion reactions
due to leukocyte antibodies
Indication:
o Increase RBC mass in patients at risk for HLA alloimmunization or susceptible to
cytomegalovirus (CMV)
Storage:
o Close system: same as RBCs
Shelf Life:
o Open system

Washed RBCs
o Increase RBC mass of symptomatic anemic patients with transfusion history of:
• allergic, urticarial reaction
Indication: • anaphylactic reaction
• febrile nonhemolytic reaction
o Used in infant or intrauterine transfusion
Storage:
Shelf Life:

Irradiated RBCs
Preparation: o Recommended minimum dose of gamma irradiation is _____
o Immunodeficiency, malignancy, bone marrow transplant, transfusion with blood from
Indication:
blood relative, intrauterine and neonatal transfusion
Storage:
Shelf Life: o Original outdate or __________ from irradiation, whichever comes 1st

Frozen RBCs
Preparation: o Frozen in glycerol within __________ of collection
Indication: o Storage of rare blood and autologous units
Storage and o Frozen: __________
Shelf Life: o After deglycerolization: 24 hours (unless closed system used)
o Osmolality to monitor glycerol removal
Others:
o Virtually all plasma, anticoagulant, WBCs, and platelets removed


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 o Methods of Freezing Red Cells:
Method Reagent Frozen at Type of Freezer Stored at
High Glycerol


Low Glycerol


Agglomeration


o Deglycerolization: wash RBCs in _______________ solution followed by an _______________ solution
• High glycerol: 12% NaCl → 1.6% NaCl → 0.9% NaCl + 0.2% dextrose
• Low glycerol: 4.5% NaCl in 15% mannitol → 0.9% NaCl
• Agglomeration: 50% glucose + 5% fructose → 0.9% NaCl

2. Platelets
• Indications:
o Platelet count less than 5,000 to 10,000/μL without hemorrhage, or
• hemorrhage and platelet count less than 50,000/μL, or
• operative procedure and platelet count less than 50,000/μL, or
• antiplatelet drugs
o Others:
• Thrombocytopenia with bleeding or invasive procedure
• Chemotherapy for malignancy
• Disseminated intravascular coagulation
• Massive transfusion
• Outcome:
o Platelet count immediately before and 10 minutes to 1 hour post-transfusion except with antiplatelet
drugs
o 1 unit of random donor platelet (RDP) should ↑ platelets by ____________________ in 75-kg recipient
o 1 unit of single donor platelet (SDP) should ↑ platelets by ____________________ in 75-kg recipient

Platelet Concentrate or Random Donor Platelet (RDP)

Preparation: o Centrifugation of whole blood at room temperature within __________ of collection
o For bleeding due to thrombocytopenia or thrombocytopathy; for patients with
Indication: chemotherapy, post-bone marrow transplant patients, post-operative bleeding
o NOT indicated in patients with idiopathic thrombocytopenia (ITP)
Storage:
o __________ from collection with constant agitation
Shelf Life:
o After pooling: __________
o 1 unit contains _______________ platelets
o Volume: __________
Others:
o pH: __________
o Should not be used if visible aggregates present; may contain residual RBCs

Single Donor Platelet (SDP) or Plateletpheresis Unit
Preparation: o Apheresis
o For thrombocytopenic patients alloimmunized to HLA or platelet antigen
Indication: o Limit the donor exposure in thrombocytopenic patients who acquire long term platelet
transfusions
Storage:
Shelf Life: o __________ with constant agitation
o 1 unit contains _______________ platelets
Others: o Volume: __________
o pH: __________

Leukocyte-Reduced Platelets
o WBCs removed by filtration or during apheresis processing
Preparation:
o Filters can reduce number of leukocytes in a bag while being transfused
Indication: o Same with SDP
Storage:
o Open system: __________
Shelf Life:

o Apheresis: __________ with agitation
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 Pre-storage Pooled Platelets
Preparation: o 4-6 ABO identical platelet pooled using closed system
Indication: o Severe thrombocytopenia or abnormal platelet function
Storage:
Shelf Life: o __________ from collection with agitation
o Extended outdate overcomes need for transfusion service to pool just before
Others:
administration

• Note:
o Conditions Causing Platelet Refractoriness or Poor Response to Platelet Transfusions
• Immune:
o HLA alloantibodies o Autoantibodies
o Platelet alloantibodies
• Non-immune:
o Splenomegaly o Active bleeding
o Medications o Disseminated intravascular hemolysis (DIC)
o Sepsis o Fever
o Guidelines for the Effectiveness of Platelet Transfusion
• Corrected Count Increment (CCI)
o Refers to relative increase in platelet count adjusted for the number of platelets transfused and
the size of the patient
o CCI Interpretation for Platelets
• Good increment: _______________
• Refractoriness: _______________
• Percent Recovery:
o _____ at 1 hour
o _____ at 24 hours

3. Granulocyte
• Indications: Granulocytes are limited to patients with the following conditions:
o Neutropenia
o Documented infections, especially gram-negative bacteria and fungi
o Lack of response to antibiotics

Apheresis Granulocytes or Granulocyte Pheresis Unit
o Apheresis
Preparation o Hydroxyethyl starch (HES)
o Administer corticosteroid to donor 12-24 hours before donation
o Patients with granulocyte dysfunction or myeloid hypoplasia who are unresponsive to
antibiotics
Indication:
o Severe neutropenia with infection non-responsive to antibiotic therapy
o Limited to septic infants
Storage:
Shelf Life:
Others: o 1 unit contains _______________ granulocytes, platelets, and 20-50 mL of RBCs


4. Plasma and Derivatives
a. Plasma
o Indications:
• Patients with bleeding or invasive procedure
• PTT greater than __________ or INR greater than __________

Fresh Frozen Plasma (FFP)
o Plasma separated from WB and frozen within _____ of collection

o FFP → thaw in waterbath at 30°-37°C for 30-45 minutes à thawed plasma

Preparation: Note: Thawed plasma from FFP

→ Transfuse immediately
→ Store at 1°-6°C for up to __________; or
→ Store at 4°C for up to __________ if factor VIII is not needed

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 Fresh Frozen Plasma (FFP) continued
o Bleeding patients who require factors II, V, VII, IX, and X
o Replace isolated factor deficiencies when specific component is not available
o Reverse effects of Warfarin (Coumadin; Panwarfin; Sofarin) anticoagulant drug
o Treatment of thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic
Indication:
syndrome
o Patients with liver disease to prevent or correct bleeding
o Antithrombin III deficiencies; disseminated intravascular coagulation when fibrinogen is
less than 100 mg/dL
Storage and o Frozen: at <–18°C __________; at <–65°C __________;
Shelf Life: o After thawing: 1°-6°C _____
Others: o Check for evidence of thawing and refreezing

b. Cryoprecipitate
o Indication: Fibrinogen deficiency or factor XIII deficiency
o Outcome: Fibrinogen or factor XIII determination after transfusion
Cryoprecipitate
o Prepared by thawing FFP at 1°-6°C, removing plasma, and refreezing within __________
o FFP → thaw at 4°C → centrifuge: _______________ à white mass of precipitate
• Contains:
• Fibrinogen __________
• AHF VIII:c __________
• vWf __________
Preparation: • F XIII __________
o Before infusion: Frozen cryoprecipitate à thaw at 30°-37°C à thawed cryoprecipitate
Note: Thawed cryoprecipitate
→ store at room temperature and transfuse immediately; or
→ transfuse within _____ hours

Pooled cryoprecipitate (after thawing)

→ transfuse within _____ hours
o For treatment of fibrinogen deficiency, hemophilia A, von Willebrand’s disease and
factor XIII deficiency, and as a fibrin sealant
Indication: Note:
• Patients with FVIII deficiency are routinely treated with ____________________
• Not indicated for thrombotic thrombocytopenic purpura (TTP)
o Frozen: <–18°C
Storage:
o After thawing: Room Temperature
o Frozen: 12 months
o After thawing
Shelf Life:
• Single units: ___ hours
• Pooled units: close system ___ hours; open system ___ hours

c. Plasma Derivatives
o Preparation:
• Plasma other than that prepared as FFP may be separated from whole blood at any time during the
unit’s shelf life up to ___________ after the expiration date
• The plasma may be pooled, purified, or fractionated into plasma derivatives
o Shelf Life:
• Plasma derivatives have a shelf life of 5 years when stored between 1°C and 6°C
o Plasma Derivatives:
1) Albumin
o Prepared by chemical and physical fractionation of pooled plasma
o Used to treat patients requiring volume replacement

2) Normal Serum Albumin (NSA)

o Prepared from salvaged plasma, pooled and fractionated by a cold alcohol process, then treated
with heat inactivation (60°C for 10 hours)
o Indicated in patients who are hypovolemic and hypoproteinemic and in clinical settings for
shock and burn patients

3) Plasma protein fraction (PPF)

o Sterile pooled plasma stored as a fluid or freeze-dried and used for volume replacement
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 4) Immune serum globulin (ISG)
o Gamma globulin protein fraction of serum-containing antibodies
o Indicated for patient with immunodeficiency diseases and for providing passive antibody
prophylaxis against hepatitis and herpes

5) Immune globulin
o Used for patients with congenital hypogammaglobulinemia and for patients exposed to diseases
such as hepatitis A or measles
o For hypogammaglobulinemia, monthly injections are usually given where the recommended
dose is 0.7 mL/kg intramuscularly or 100 mg/kg intravenously
o For hepatitis A prophylaxis, 0.02 to 0.04 mL/kg intramuscularly is recommended

Coagulation Factors and Their Sources
Factor Name Indication Source
Factor I (fibrinogen) Fibrinogen deficiency Fibrinogen concentrate,
Cryoprecipitated AHF
Factor II, IX, X (prothrombin complex) Hemophilia B Prothrombin complex
concentrate
Protein C Venous thrombosis, severe Protein C concentrate
protein C deficiency
Factor VIIa (recombinant) Factor VII deficiency, hemophilia Recombinant factor VIIa
A or B with inhibitors concentrate
Activated prothrombin complex [factor Bleeding or prophylaxis before Activated Prothrombin complex
II, IX, X (nonactivated), VII surgery for hemophilia A or B concentrate
(activated)] with inhibitors
Factor VIII (Antihemophilic factor) Hemophilia A, von Willebrand’s Factor VIII concentrate, human
disease and recombinant
Factor IX (Christmas factor) Hemophilia B Factor IX concentrate, human
and recombinant
Factor XI (Plasma thromboplastin Factor XI deficiency Thawed plasma, FFP, PF24
antecedent)
Factor XIII (Fibrin stabilizing factor) Factor XIII deficiency Cryoprecipitated AHF or Plasma
von Willebrand’s factor (vWf) von Willebrand’s disease Factor VIII concentrate,
Cryoprecipitated AHF, FFP

C. Blood Substitutes
o RBC substitutes under investigation include:
1. Hemoglobin-based oxygen carriers (HBOCs)
o Diaspirin cross-linked Hgb from outdated human RBCs
o Polymerized and pyridoxalated human Hgb
o Polymerized bovine Hgb: Product name Hemopure (HBOC-201)
o Polymerized bovine Hgb: Product name Oxyglobin
o Polyethylene glycol (PEG) attached to the surface of Hgb from human RBCs
o Purified human Hgb from outdated RBCs, cross-linked and polymerized
o Derived from bovine Hgb
o Liposome-encapsulated hemoglobin
2. Perfluorocarbons (PFCs)
o Fluosol-DA o Oxyfluor o Perftoran
o Oxygent o Oxycyte

D. Plasma Volume Expander
o Products that are transfused in patients suffering from hypovolemia or indicated among burn and shock patients
1. Plasma-derived volume expander
o Normal Serum Albumin (NSA)
o Plasma Protein Fraction (PPF)
2. Synthetic volume expander
o Crystalloids:
• Ringer’s Lactate (Na, Cl, K, Ca, lactate ions)
• Normal Saline Solution (0.85%-0.90% NaCl)
o Colloids:
• Dextran (6-10%)
• Hydroxyethyl starch (HES)


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 Note:
o Effects of Storage on Whole Blood
• Metabolism continues in the red blood cells
• Platelets with some plasma proteins lose their biological activity
• Biochemical and metabolic effects:
o Reduction in the pH (blood becomes more ___________ )
o Rise in plasma potassium concentration (extracellular K+)
o Progressive reduction in the red cell content of 2,3-diphosphoglycerate (2,3-DPG) which may reduce the
release of oxygen at tissue level
o Loss of platelet function in whole blood within 48 hours of donation
o Reduction of factor VIII to __________ of normal within 48 hours of donation
Coagulation factors such as _____ and _____ are relatively stable on storage

o RBC Storage Lesions
Increased Decreased Other Changes
• Lactic acid • ATP • Shift to left of O2 dissociation
• Plasma K+ • 2,3-DPG curve (↑ Hgb/O2 affinity, ↓ O2
• Plasma hemoglobin • pH delivery to tissues)
• Microaggregates • Glucose
• Viable cells
• Labile coagulation factors

o Component Quality Control
Component Specifications and Standards
Red Blood Cells (RBCs) • Hematocrit __________
RBCs Leukocyte-Reduced • Retain __________ of original red cells
• _______ of tested units __________ leukocytes in the final container
Cryoprecipitated AHF • Factor VIII: __________
• Fibrinogen: __________
Platelets • __________ platelets per unit and pH ≥6.2 in _____ of units tested
Platelets Leukocyte-Reduced • __________ platelets in 75% of units tested, ≥6.2 pH in _____ of
units tested, and __________ leukocytes in _____ of units tested
Platelets Pheresis • __________ platelets in final container of components tested; and
pH ≥6.2 in _____ of units tested
Platelets Pheresis Leukocyte- • __________ leukocytes in _____ of components tested and
Reduced __________ platelets in the final container and pH ≥6.2 in _____
tested units
Granulocytes Pheresis • __________ granulocytes in at least _____ of components tested
Irradiated components • __________ delivered to the central portion of the container;
minimum of __________at any point in the component

TRANSFUSION THERAPY
• The administration of blood or its component intravenously
• Types:
1. Allogeneic transfusion
2. Autologous transfusion: Blood taken from a patient to be used for the same patient
3. Direct transfusion: Transfer of blood directly from one person to another
4. Indirect transfusion: Transfusion of blood from a donor to a suitable container and then to a patient
5. Exchange transfusion: Transfusion and withdrawal of small amounts of blood, repeated until blood volume is
almost entirely exchanged; Used in infants born with hemolytic disease
6. Intrauterine transfusion: Transfusion of blood into a fetus in utero

• Maximum Surgical Blood Ordering Schedule (MSBOS) or Maximum Blood Ordering Schedule (MBOS)
o Purpose of Surgical Blood Ordering Schedule: Reduce unnecessary crossmatching

• Infusion of Blood Components:

1. Positive identification of the patient, sample, and crossmatched unit
• At the time of specimen collection
• At the time of blood transfusion

2. Only normal saline should be infused with blood components

• Normal saline solution (NSS) is employed to start an IV prior to instituting blood transfusion
o Others: 4% albumin, Plasma Protein Fraction (PPF) and ABO Compatible Plasma
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 o Do NOT use:
• 5% dextrose in water (D5W)
• Ringer’s lactate solution
• Diluting the Packed RBC
o To decrease the viscosity and allow increased rates of infusion by: Normal Saline Solution (NSS); ABO
compatible plasma (seldom); 5% albumin

3. A standard 170 µm filter must be used with all components

• Blood components and derivatives are transfused through filters to remove fibrin clots and other particulate
debris
• Types of filter:
o First generation filters: pore size of 170 µm → used to remove fibrin clots
o Second generation filters: Microaggregate filter with pore size 20-40 µm → used to remove platelets,
degenerating WBC, cell fragments, nuclei and fibrin
o Third generation filters: Leukoreduction Filters → used to remove 99.9% of WBC from RBC and platelet
products leaving less than 5 x 106 WBC in their respective components

4. Peripheral vein cannula for transfusion

• For adults: __________
• For pediatric patients: __________

5. The maximum transfusion time allowed for one unit to be transfused is 2-4 hours
• In most administration sets: 15 drops = 1 mL
• At a rate of 60 drops per minute, 240 mL of blood can be transfused in 1 hour
• Under normal conditions for an average adult: 1 unit of blood should be infused within 1 or 2 hours
• If the blood is to be transfused slowly, the transfusion should be completed within 4 hours
• Time limits for infusion of blood units:
Blood Start of Infusion Complete Infusion
Whole blood or Within 30 minutes* of removing pack Within _____ hours (or less than 1
Red cells from the refrigerator hour in high ambient temperature)
Platelet concentrate Immediately Within _____ minutes
As soon as possible after thawing to
Fresh frozen plasma Within _____ minutes
avoid loss of labile clotting factors

6. Blood warmer
• The blood warmer should maintain a temperature of about _____
• Recommended for:
o Patients receiving many units of blood in a short period of time
o In massive transfusion
o In exchange transfusion
o In transfusion of premature infants
o In patients with strong cold agglutinins

7. Documentation and accurate recordkeeping are vital

• Special Categories:
1. Autologous transfusion
• Blood taken from a patient to be used for the same patient
• Types:
a. Predeposit for scheduled surgery
• Predeposit autologous blood donation refers to blood that is withdrawn before an anticipated
transfusion and stored until use
• For patients with multiple RBC antibodies or antibodies to high incidence antigens
• Regular donation procedure
• Blood stored as liquid or frozen
• Iron supplements
• General requirements:
o Age o Frequency of donation
o Weight o Hemoglobin and hematocrit
o Volume to be collected o Medical history

b. Intraoperative hemodilution
• Collection of 1-2 units of blood from the patient just before the surgical procedure, replacing the
blood volume with crystalloid or colloid solution
• At the end of surgery blood units are infused into the patient
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 c. Immediate preoperative hemodilution
• Takes place in the operating room when 1-3 units of whole blood are collected and the patient’s
volume is replaced by colloid or crystalloid
• The blood is reinfused during the surgical procedure

d. Intraoperative autologous transfusion

• Occurs when blood is collected during surgical procedure and usually reinfused immediately
• Intraoperative salvage*
o A procedure to reclaim a patient’s blood loss from an operation by reinfusion

e. Postoperative salvage*
• An autologous donation in which a drainage tube is placed in the surgical site and postoperative
bleeding is salvaged, cleaned and reinfused
o Collect blood from surgical drains and delivered into sterile containers; collected blood must be
transfused within 6 hours
*Equipments: collecting, washing and filtering the shed blood before reinfusion

2. Hemapheresis/apheresis blood collection
• Blood is drawn from a donor or a patient and separated into components; one or more of the components is
retained, and the remaining constituents are recombined and returned to the individual
• Donor criteria same as for whole blood
• Frequency of donation:
a. Plateletpheresis: platelet count of 150,000/µL; 48 hours required between donations, up to 24
times/year
b. Leukopheresis: not more than twice a week, 24 times/year
c. Plasmapheresis: every 4 weeks; total protein, IgG and IgM monitored
d. Red cell pheresis: every 16 weeks
• Methods:
a. Centrifugation: Withdrawal of whole blood, removing selected fraction and reinfusion of the remaining
components into the donor
1) Intermittent-flow centrifugation (IFC)
o Requires only one venipuncture, in which blood is withdrawn and reinfused to the same needle
o Once the desired component is separated, the remaining components are reinfused to the
donor, and one cycle is complete
2) Continuous-flow centrifugation (CFC)
o Two venipuncture sites are necessary
o Procedure includes withdraw, process, and return of the blood to the individual simultaneously
b. Filtration: Removal of only plasma through a membrane for normal plasma collection or for therapeutic
purposes
c. Adsorption: Removal of only a selected constituent of plasma with reinfusion of plasma after
constituent removed

3. Therapeutic bleeding
• One unit of blood is removed from a patient in a specified time interval
• This is done to treat patient symptoms such as:
o Plateletpheresis: polycythemia vera
o Leukapheresis: leukemia
o Plasmapheresis: systemic lupus erythematosus

4. Massive blood transfusion

• Defined either as the administration of 8 to 10 RBC units to an adult patient in less than 24 hours, or as the
acute administration of 4 to 5 RBC units in 1 hour
• Replacement of one or more blood volume(s) within 24 hours or about 10 units of blood in an adults
• Can lead to citrate overload; can be alleviated by calcium chloride or calcium gluconate injections

5. Emergency transfusion result from trauma and surgical needs

• Includes the use of:
o Group O, Rh-negative packed RBCs
o Fluid resuscitation with crystalloids and colloids
o Reserve transfusion for patients losing more than 20% of their blood volume

6. Neonatal RBC Transfusions

• Aliquoted units: less than 7 days old, unless infused slowly; O-negative or compatible with mother and
infant; CMV-negative or leukocyte-reduced; Hemoglobin S-negative for hypoxic newborns
• Dose: 10 mL/kg over 2 to 3 hours

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