Bb unit2 bloodcomponentsspring2010

II. Blood and Blood II. Blood and Blood ComponentsComponents

Terry Kotrla, MS, MT(ASCP)BBTerry Kotrla, MS, MT(ASCP)BBSpring 2010Spring 2010

Goals Of Blood CollectionGoals Of Blood Collection Maintain viability and functionMaintain viability and function Prevent physical changesPrevent physical changes Minimize bacterial contaminationMinimize bacterial contamination

Anticoagulants Preservative Solutions

Anticoagulants prevent blood clottingAnticoagulants prevent blood clotting Preservatives provide nutrients for cellsPreservatives provide nutrients for cells HeparinHeparin

– Rarely if ever used anymoreRarely if ever used anymore– Anticoagulant ONLYAnticoagulant ONLY– Transfuse within 48 hours, preferably 8Transfuse within 48 hours, preferably 8

AnticoagulantsAnticoagulants

CPDCPD CPD-A1CPD-A1Storage timeStorage time 21 days21 days 35 days35 daysTemperatureTemperature 1-6 C1-6 C 1-6 C1-6 C

Slows glycolytic activitySlows glycolytic activityAdenineAdenine NoneNone Substrate for ATP synthesisSubstrate for ATP synthesisVolumeVolume 450 +/- 10%450 +/- 10%DextroseDextrose Supports ATP generation by glycolytic Supports ATP generation by glycolytic

pathwaypathwayCitrateCitrate Prevents coagulation by binding calciumPrevents coagulation by binding calcium

Additive SolutionAdditive Solution Primary bag with satellite bags attached.Primary bag with satellite bags attached. One bag has additive solution (AS)One bag has additive solution (AS) Unit drawn into CPD anticoagulantUnit drawn into CPD anticoagulant

Additive SolutionAdditive Solution Remove platelet rich plasma within 72 hoursRemove platelet rich plasma within 72 hours Add additive solution to RBCs, ADSOL, which Add additive solution to RBCs, ADSOL, which

consists of:consists of:– SalineSaline– AdenineAdenine– GlucoseGlucose– MannitolMannitol

Extends storage to 42 daysExtends storage to 42 days Final hematocrit approximately 66%Final hematocrit approximately 66%

Changes Occur During StorageChanges Occur During Storage Shelf life = expiration dateShelf life = expiration date

– At end of expiration must have 75% recoveryAt end of expiration must have 75% recovery– At least 75% of transfused cells remain in At least 75% of transfused cells remain in

circulation 24 hours AFTER transfusioncirculation 24 hours AFTER transfusion

Storage LesionStorage Lesion Biochemical changes which occur at 1-6CBiochemical changes which occur at 1-6C Affects oxygen dissociation curve, increased Affects oxygen dissociation curve, increased

affinity of hemoglobin for oxygen.affinity of hemoglobin for oxygen.– Low 2,3-DPG, increased OLow 2,3-DPG, increased O22 affinity, less O affinity, less O22 released. released.– pH drops causes 2,3-DPG levels to fallpH drops causes 2,3-DPG levels to fall– Once transfused RBCs regenerate ATP and 2,3-DPGOnce transfused RBCs regenerate ATP and 2,3-DPG

Few functional platelets presentFew functional platelets present Viable (living) RBCs decreaseViable (living) RBCs decrease

Plasma hemoglobin

Plasma K+

Viable cells

pH

ATP

2,3-DPG

Plasma Na+

Helps release oxygen from hemoglobin (once transfused, ATP & 2,3-DPG return to normal)

K+Na+

Storage LesionStorage Lesion Significant for infants and massive Significant for infants and massive

transfusion.transfusion. Other biochemical changesOther biochemical changes

– ATP decreasesATP decreases– Potassium increasesPotassium increases– Sodium decreasesSodium decreases– Plasma hemoglobin increasesPlasma hemoglobin increases

Preparation of ComponentsPreparation of Components Collect unit within 15 minutes to prevent Collect unit within 15 minutes to prevent

activation of coagulation systemactivation of coagulation system Draw into closed system – primary bag with Draw into closed system – primary bag with

satellite bags with hermetic seal between.satellite bags with hermetic seal between. If hermetic seal broken transfuse within 24 hours If hermetic seal broken transfuse within 24 hours

if stored at 1-4C, 4 hours if stored at 20-24Cif stored at 1-4C, 4 hours if stored at 20-24C

Preparation of ComponentsPreparation of Components Centrifuge – light spin, platelets suspendedCentrifuge – light spin, platelets suspended Remove platelet rich plasma (PRP)Remove platelet rich plasma (PRP) Centrifuge PRP heavy spinCentrifuge PRP heavy spin Remove platelet poor plasmaRemove platelet poor plasma Freeze plasma solid within 8 hoursFreeze plasma solid within 8 hours Thaw plasma at 1-4C – precipitate formsThaw plasma at 1-4C – precipitate forms Centrifuge, express plasma leaving Centrifuge, express plasma leaving

cryoprecipitate. Store both at -18Ccryoprecipitate. Store both at -18C RBCs – CPD – 21 days, ADSOL – 42 days – 1-RBCs – CPD – 21 days, ADSOL – 42 days – 1-

6C6C

Preparation of ComponentsPreparation of Components Summary – One unit of whole blood can Summary – One unit of whole blood can

produce:produce:– Packed RBCsPacked RBCs– Fresh frozen plasma (FFP)Fresh frozen plasma (FFP)– Cryoprecipitate (CRYO)Cryoprecipitate (CRYO)– Single donor plasma (SDP) – cyro removedSingle donor plasma (SDP) – cyro removed– Platelets – terms PC (platelet concentrate) OR Platelets – terms PC (platelet concentrate) OR

RD PC (random donor platelet concentrate)RD PC (random donor platelet concentrate)

Preparation of ComponentsPreparation of Components Sterile docking device joins tubingSterile docking device joins tubing

– Used to add satellite bags to maintain original Used to add satellite bags to maintain original expiration of componentexpiration of component

– May be used to pool componentsMay be used to pool components

Blood Component General InformationBlood Component General Information

Blood separated into components to Blood separated into components to specifically treat patients with product specifically treat patients with product neededneeded

Advantages of component separationAdvantages of component separation– Allow optimum survival of each componentAllow optimum survival of each component– Transfuse only component neededTransfuse only component needed


Transfusion practiceTransfusion practice– Transfusion requires doctor’s prescriptionTransfusion requires doctor’s prescription– All components MUST be administered All components MUST be administered

through a filterthrough a filter– Infuse quickly, within 4 hoursInfuse quickly, within 4 hours– D (Rh) neg require D neg cellular productsD (Rh) neg require D neg cellular products– ABO identical preferred, ABO compatible OKABO identical preferred, ABO compatible OK– ““Universal donor” – RBCs group O, plasma Universal donor” – RBCs group O, plasma

ABAB


Fresh Whole BloodFresh Whole Blood– Blood not usually available until 12-24 hoursBlood not usually available until 12-24 hours– CandidatesCandidates

Newborns needing exchange transfusionNewborns needing exchange transfusion Patients requiring leukoreduced productsPatients requiring leukoreduced products


Summary of storage temperatures:Summary of storage temperatures:– Liquid RBCs 1-6CLiquid RBCs 1-6C– Platelets, Cryo (thawed) and granulocytes 20-Platelets, Cryo (thawed) and granulocytes 20-

24C (room temperature)24C (room temperature)– ANY frozen plasma product ≤ -18CANY frozen plasma product ≤ -18C– ANY liquid plasma product EXCEPT Cryo 1-ANY liquid plasma product EXCEPT Cryo 1-

6C6C

Blood ComponentsBlood Components CellularCellular

– Red blood cell productsRed blood cell products– PlateletsPlatelets– GranulocytesGranulocytes

PlasmaPlasma– FFPFFP– CryoprecipitateCryoprecipitate

Products With Red CellsProducts With Red Cells

Whole BloodWhole Blood Clinical indications for use of WB are extremely limited. Used for massive transfusion to correct acute

hypovolemia such as in trauma and shock, exchange transfusion.

RARELY used today, platelets non-functional, labile coagulation factors gone.

Must be ABO identical.

Changes in Stored BloodChanges in Stored Blood

Red Blood Cells, Packed Red Blood Cells, Packed (PRBC)(PRBC)

Used to treat symptomatic anemia and routine blood loss during surgery

Hematocrit is approximately 80% for non-additive (CPD), 60% for additive (ADSOL).

Allow WB to sediment or centrifuge WB, remove supernatant plasma.

Leukocyte Reduced Red Cells (LR-Leukocyte Reduced Red Cells (LR-RBC)RBC)

Leukocytes can induce adverse affects during transfusion, primarily febrile, non-hemolytic reactions.

Reactions to cytokines produced by leukocytes in transfused units. Other explanations to reactions include: immunization of recipient to

transfused HLA or granulocyte antigens, micro aggregates and fragmentation of granulocytes.

Historically, indicated only for patients who had 2 or more febrile transfusion reactions, now a commonly ordered, popular component.

“CMV” safe blood, since CMV lives in WBCs. Most blood centers now leukoreduce blood immediately after

collection. Bed side filters are available to leukoreduce products during

transfusion.

Leukocyte ReductionLeukocyte Reduction

Washed Red Blood Cells (W-RBCs)

Washing removes plasma proteins, platelets, WBCs and micro aggregates which may cause febrile or urticarial reactions.

Patient requiring this product is the IgA deficient patient with anti-IgA antibodies.

Prepared by using a machine which washes the cells 3 times with saline to remove and WBCs.

Two types of labels:– Washed RBCs - do not need to QC for WBCs.– Leukocyte Poor WRBCs, QC must be done to guarantee

removal of 85% of WBCs. No longer considered effective method for leukoreduction.

e. Expires 24 hours after unit is entered.

Cell Washer to Prepare Washed Cell Washer to Prepare Washed CellsCells

Frozen BloodFrozen Blood

Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Blood is frozen to preserve: rare types, for autologous transfusion, stock piling blood for military mobilization and/or civilian natural disasters.

Blood is drawn into an anticoagulant preservative.– Plasma is removed and glycerol is added.– After equilibration unit is centrifuged to remove excess glycerol

and frozen. Expiration

– If frozen, 10 years.– After deglycerolization, 24 hours.

Storage temperature– high glycerol -65 C.– low glycerol -120 C, liquid nitrogen.

Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Thaw unit at 37C, thawed RBCs will have high concentration of glycerol.

A solution of glycerol of lesser concentration of the original glycerol is added.

This causes glycerol to come out of the red blood cells slowly to prevent hemolysis of the RBCs.

After a period of equilibration the unit is spun, the solution is removed and a solution with a lower glycerol concentration is added.

This procedure is repeated until all glycerol is removed, more steps are required for the high glycerol stored units.

The unit is then washed.

Rejuvenated Red Blood Cells

A special solution is added to expired RBCs up to 3 days after expiration to restore 2,3-DPG and ATP levels to prestorage values.

Rejuvenated RBCs regain normal characteristics of oxygen transport and delivery and improved post transfusion survival.

Expiration is 24 hours or, if frozen, 10 years

Platelet ProductsPlatelet Products

Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

Used to prevent spontaneous bleeding or stop established bleeding in thrombocytopenic patients.

Prepared from a single unit of whole blood. Due to storage at RT it is the most likely component to

be contaminated with bacteria. Therapeutic dose for adults is 6 to 10 units. Some patients become "refractory" to platelet therapy. Expiration is 5 days as a single unit, 4 hours if pooled. Store at 20-24 C (RT) with constant agitation. D negative patients should be transfused with D negative

platelets due to the presence of a small number of RBCs.

Preparation of platelet Preparation of platelet concentrateconcentrate

RBCs PRP

Plasma

Platelet concentrate

Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

One bag from ONE donorOne bag from ONE donor Need 6-10 for therapeutic doseNeed 6-10 for therapeutic dose

Pooling PlateletsPooling Platelets 6-10 units transferred into one bag6-10 units transferred into one bag Expiration = 4 hoursExpiration = 4 hours

Platelets Pheresis, Apheresis Platelet Concentrate, Single Donor Platelet Concentrate (SD-PC)

Used to decrease donor exposure, obtain HLA matched platelets for patients who are refractory to RD-PC or prevent platelet refractoriness from occurring.

Prepared by hemapheresis, stored in two connected bags to maintain viability.

One pheresed unit is equivalent to 6-8 RD-PC. Store at 20-24 C (RT) with agitation for 5 days, after

combining, 24 hours D negative patients should be transfused with D negative

platelets due to the presence of a small number of RBCs

ApheresisApheresis

ApheresisApheresis

Platelets Pheresis

One bag (unit) from One bag (unit) from one donorone donor

One unit is a One unit is a therapeutic dosetherapeutic dose

Volume Volume approximately 250 approximately 250 ccsccs

GranulocytesGranulocytes

Lymphocyte Monocyte

Neutrophils Eosinophils Basophils

Granulocytes Primary use is for patients with neutropenia who have

gram negative infections documented by culture, but are unresponsive to antibiotics.

Therapeutic efficacy and indications for granulocyte transfusions are not well defined.

Better antimicrobial agents and use of granulocyte and macrophage colony stimulating factors best for adults, best success with this component has been with babies

Daily transfusions are necessary. Prepared by hemapheresis. Expiration time is 24 hours but best to infuse ASAP. Store at 20-24 C.

Plasma ComponentsPlasma Components

Fresh Frozen Plasma – Fresh Frozen Plasma – Volume 200-250ccVolume 200-250cc

Fresh Frozen Plasma (FFP)

Used to replace labile and non-labile coagulation factors in massively bleeding patients OR treat bleeding associated with clotting factor deficiencies when factor concentrate is not available.

Must be frozen within 8 hours of collection. Expiration

– frozen - 1 year stored at <-18 C.– frozen - 7 years stored at <-65 C.thawed - 24 hours

Fresh Frozen Plasma (FFP)

Storage temperature– frozen -18 C, preferably -30 C or lower– thawed - 1-6 C

Thawed in 30-37C water bath or FDA approved microwave

Must have mechanism to detect units which have thawed and refrozen due to improper storage.

Must be ABO compatible

Plasma, Liquid Plasma, Recovered Plasma and Source Plasma

Used to treat patients with stable clotting factor deficiencies for which no concentrate is available or for patients undergoing therapeutic plasmapheresis.

Prepared by separating the plasma from the RBCs on or before the 5th day after expirat ion of the whole blood.

Once separated can:– Freeze, store at -18 C for 5 years– If not frozen, called liquid plasma, store at 1-6 C for up to 5 days

after expiration of WB. Once FFP is one year old can redesignate as Plasma,

expiration is 5 years.

Pooled Plasma/Solvent Detergent Treated

Most recently licensed product. Prepared from pools of no more than 2500 units of ABO

specific plasma frozen to preserve labile coagulation factors.

Treated with chemicals to inactivate lipid-enveloped viruses.

Contains labile and non-labile coagulation factors but lacks largest Von Willebrand’s factor multimers.

Used same as FFP.Safety concerns– Decreases disease transmission for diseases tested for.– Doesn’t inactivate viruses with non-lipid envelopes: parvo virus

B19, hepatitis A, and unrecognized pathogens

Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Cold insoluble portion of plasma that precipitates when FFP is thawed at 1-6C.

Cryoprecipitate contains high levels of Factor VIII and Fibrinogen, used for treatment of hemophiliacs and Von Willebrands when concentrates are not available.

Used most commonly for patients with DIC or low fibrinogen levels.

A therapeutic dose for an adult is 6 to 10 units. Can be prepared from WB which is then designated as

"Whole Blood Cryoprecipitate Removed" or from FFP– Plasma is frozen.– Plasma is then thawed at 1-6 C, a precipitate forms.– Plasma is centrifuged, cryoprecipitate will go to

bottom.– Remove plasma, freeze within 1 hour of preparation

FFP

Frozen within 8 hours

Thawed FFP

Cryoprecipitate (VIII, vW)

Plasma cryoprecipitate, reduced (TTP, FII, V, Vii, IX, X, XI)

Thaw at 30-37°C Store at RT 4 hrs

Refrozen with 24 hrs of separation Store at ≤18°C 1 yr

5 day expiration at 1-6°C

Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Storage Temperature– Frozen -18 C or lower– Thawed - room temperature

Expiration:– Frozen 1 year– Thawed 6 hours– Pooled 4 hours

Best to be ABO compatible but not important due to small volume

Cryoprecipitate – volume 15ccsCryoprecipitate – volume 15ccs

Irradiation of Blood Components

Irradiation of Blood Components Cellular blood components are irradiated to

destroy viable T- lymphocytes which may cause Graft Versus Host Disease (GVHD).

GVHD is a disease that results when immunocompetent, viable lymphocytes in donor blood engraft in an immunocompromised host, recognize the patient tissues as foreign and produce antibodies against patient tissues, primarily skin, liver and GI tract. The resulting disease has serious consequences including death.

GVHD may be chronic or acute

Irradiation of Blood Components Patients at greatest risk are:

– severely immunosuppressed,– immunocompromised, – receive blood donated by relatives, or – fetuses receiving intrauterine transfusions

Irradiation inactivates lymphocytes, leaving platelets, RBCs and granulocytes relatively undamaged.

Must be labeled "irradiated". Expiration date of Red Blood Cell donor unit changes to

28 days. May be transfused to "normal" patients if not used by

intended recipient.

Irradiation of Blood Components

Donor Blood Inspection and Disposition

It is required that donor units be inspected periodically during storage and prior to issuing to patient.

The following may indicate an unacceptable unit:– Red cell mass looks purple or clots are visible.– Zone of hemolysis observed just above RBC mass, look for

hemolysis in sprigs, especially those closest to the unit.– Plasma or supernatant plasma appears murky, purple, brown or

red.– A greenish hue need not cause a unit to be rejected.– Inspect platelets for aggregates.

Inspect FFP and CRYO for signs of thawing, evidence of cracks in bag, or unusual turbidity in CRYO or FFP (i.e., extreme lipemia).

Inspection of Donor BloodInspection of Donor Blood Segment closest to Segment closest to

unit is hemolyzed.unit is hemolyzed. May indicate bacterial May indicate bacterial

contaminationcontamination

Donor Blood Inspection and Disposition

If a unit's appearance looks questionable do the following:– Quarantine unit until disposition is decided.– Gently mix, allow to settle and observe appearance.

If bacterial contamination is suspected the unit should be cultured and a gram stain performed.

Positive blood cultures usually indicative of:– Inadequate donor arm preparation– Improper pooling technique– Health of donor - bacteremia in donor

If one component is contaminated, other components prepared from the same donor unit may be contaminated.

Inspection of Donor BloodInspection of Donor Blood Reissuing blood cannot be done unless the following

criteria is met:– Container closure must not have been penetrated or entered in

any manner.– Most facilities set 30" time limit for accepting units back, warming

above 6-10C even with subsequent cooling increases RBC metabolism producing hemolysis and permitting bacterial growth.

– Blood must have been kept at the appropriate temperature.– One sealed segment must remain attached to container.– Records must indicate that blood has been reissued and

inspected prior to reissue.

Transportation of Blood and Blood Components

WB and RBC– Sturdy well insulated cardboard and/or

styrofoam container, wet ice in ziplock bag to cool, temperature must be monitored.

– Mobile collection units should transport blood ASAP and leave at RT if platelets are to be made.

– In-house transport place in cooler with wet ice and thermometer, monitor temperature every 30 minutes.

Safe-T-Vue Temperature MonitorSafe-T-Vue Temperature Monitor


Frozen components– Temperature must be maintained at or below required

storage temperature.– Use dry ice in well insulated container.

Platelets and granulocytes– Maintain at 20-24 C.– Transport in well insulated containers without ice.

Commercial coolers available to maintain at 20-24C.


Handling donor units– Should not remain at RT unnecessarily, when

blood is issued it should be transfused as soon as possible.

– When numerous units are removed from fridge, remove fluid filled container with a thermometer at same time as blood, when temperature reaches 6 C return to fridge.

Records Must be made concurrently with each step

of component preparation, being as detailed as possible for clear understanding.

Must be legible and indelible. Must include dates of various steps and

person responsible.

EXAM 1 ONLINE

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Bb unit2 bloodcomponentsspring2010