BLOOD COMPONENTS

Ivan James B. Pano

Overview
Blood component preparation Characteristics Shelf life Storage conditions Indications Dosage Considerations

Introduction
Blood components are used like other pharmacy products to treat and manage patients. A single blood donation can provide transfusion therapy to multiple patients in the form of RBCs, platelets, fresh frozen plasma, and cryoprecipitate.

Component Preparation
Describes the manufacturing process of all components used in transfusion therapy. The appropriate use of blood and its component is of prime importance for a safety of blood transfusion.

Centrifugation
Slow/Light spin - 2000 g (RCF) x 3 minutes @ 4 C
Hard/Heavy spin - 5000 g (RCF) x 5-7 minutes @ 4 C

Preparation

Fractionated products Immune Globulin

F VIIa

F VIII F IX

Albumin

Whole Blood (WB)

Contains RBCs, WBCs, platelets and plasma Hematocrit > 38% 1-6 C ACD/CPD: 21 days CPDA-1 : 35 days volume: 450-500 mL

Indications: - massive transfusion - active brisk bleeding Dosage effect: 1 unit = 3% Hct increase = 1 g/dL Hb increase Must be ABO & Rh compatible Compatible crossmatch

 Whole Blood Modified - cryoprecipitate anti-hemophilic factor has been removed

Whole Blood Irradiated - irradiated to inhibit T-cell proliferation in the recipient - expiration date of 28 days from date of irradiation - prevent graft vs. host disease (GVHD)

Packed Red Blood Cells (PRBC)

Red blood cells with a final Hct of < 80% Overnight sedimentation or heavy spin 1-6 C ACD/CPD: 21 days CPDA-1 : 35 days Additive solution (ADSOL): 42 days Vol.: 250-300 mL

 Indication: - chronic symptomatic anemia - to increase the oxygen carrying capacity Dosage effect: 1 unit = 3% Hct increment = 1 g/dL Hb increase

Must be ABO & Rh compatible Compatible cross match

RBC Aliquots
Red blood cell aliquots for neonatal transfusion 1-6 C CPDA-1: 35 days 10 ml/kg (Hct 80%) will increase Hb by 2 g/dL ABO & Rh, & crossmatch compatible Vol.:Varies

Irradiated RBCs
expiration date of 28 days from date of irradiation 1-6C Vol.: 250-300 mL Dosage effect: 1 unit = 3% Hct increment = 1 g/dL Hb increase

 Indications -Used to inhibit the proliferation of T cells and subsequent transfusionassociated graft-versus-host disease in patients who are:
a. immunocompromised or who are receiving a bone marrow or stem cell transplant, b. fetuses undergoing a intrauterine transfusion; and c. recipients of units from blood relatives or of HLA selected platelets .

Leukocyte-Reduced RBCs
Contains RBC, few platelets & residual WBC Absolute WBC count: <5 x 106 >85% of original RBC mass Two categories: 1) Prestorage leukoreduction 2) Poststorage leukoreduction

Prestorage leukoreduction
99.9% removal of leukocytes Multiple layers of synthetic nonwoven fibers To prevent reactions caused by Biologic response modifiers (BRMs) - proinflammatory cytokines - complement fragments

Poststorage leukoreduction
Leukocytes removed in the blood bank prior to issuing blood or at the bedside before transfusion

Centrifugation: <5 x 108 WBC Filtration: <5 x 106 WBC or lower Prevent reactions caused by leukocyte antibodies but will not prevent reactions caused by BRMs

 Indications: - Febrile reactions, increase Oxygen capacity - prevent HLA sensitization -prevent transmission of Epstein-Barr virus, CMV, and human T-cell lymphotrophic virus. Dosage effect: 1 unit = 3% Hct increment = 1 g/dL Hb increase

Washed Red Blood cells

RBC, no plasma, minimal platelets Manual wash: 70-80% of WBC removed Automated wash: 90% of WBC removed 5% loss of RBC due to wash procedure 1-6 C (24 hours after wash) Volume: 180 mL

 Indications: - for preventing febrile and allergic reactions due to WBC & plasma proteins - prevent anaphylactic reaction in IgAdeficient recipients Dosage effect: 1 unit = 3% Hct increment = 1 g/dL Hb increase

Frozen, Thawed Deglycerolized Red Blood Cells

RBC, no plasma, no WBC, no platelets 95% WBC removed Up to 20% RBC loss due to the procedure Stored at -65C for 10 years 24 hours at 1-6 C after wash Indications: - supply of rare blood types - autologous transfusion Dosage effect: 1 unit = 3% Hct increment = 1 g/dL Hb increase

Cryoprotective Agents
Penetrating (Glycerol) - small molecules that cross cell membrane - prevents water from migrating outward as extracellular ice is formed prevents intracellular dehydration Non-penetrating (Hydroxyethyl starch) - large molecules form a shell around the cell - prevents loss of water and subsequent dehydration

Deglycerolizing methods
High Glycerol (40% weight per volume) - increased cryoprotection - slow, uncontrolled freezing process - require larger volume of wash solution (stored at -80C) - most widely used Low Glycerol (20% weight per volume) - minimal cryoprotection - very rapid, more controlled freezing - liquid nitrogen routinely used (stored at -120C) - temperature fluctuations cause RBC destruction

Key Steps in Freezing Red Cells using High Glycerol Concentration

Preparation

Glycerolization

Deglycerolization
Thaw frozen cells at 37C in water bath Deglycerolized cells using a continuous flow washer Apply a deglycerolize label to transfer pack; ABO, Rh, WB unit #s & expiration date Dilute unit with hypertonic 12% NaCl and let equilibrate for 5 minutes

Weigh RBCs Place cells on a shaker & add 100 ml glycerol Adjust to 260-400g 0.9% NaCl Prewarm rbcs & glycerol to 25C Stop agitation & allow cells to equilibrate 530 min Set glycerol bottles in a water bath for 15 min at 25-37C Let partially glycerolized cells flow into freezing bag; slowly add glycerol Maintain glycerolized cells at 24-32C until ready to freeze (not to exceed 4 hours) Freeze at < 65C

Label the freezing bag with name of facility, WB unit #x, ABO, Rh, date collected, date frozen, cryoprotective agent, expiration & red blood cells frozen

Wash with 1.6% NaCl until residual glycerol is <1%; wash with 0.9% NaCl+ 0.2% dextrose Store at 1-6C

Platelet concentrate
Platelet concentrates can be produced during the routine conversion of whole blood into concentrated RBCs or by apheresis Single Donor Platelet (SDP) - apheresis Random Donor Platelet (RDP) - within 8 hours of whole blood collection

Whole blood
Light spin

PRBC

Platelet rich plasma

Hard spin

Platelet concentrate Undisturbed for 1 hour at 20-24C

Continuous agitation at 20-24C

Random Donor Platelet (RDP)

At least 5.5 x 1010 platelets Plasma pH > 6.2 (50-70 ml) Shelf life of 5 days (closed system) Open system: within 6 hours 20-24C with continuous agitation Increases platelet count to 5,00010,000/uL

 Indications:
- prophylactically correct severe thrombocytopenia to prevent hemorrhage in CNS/other organs in patients undergoing chemotherapy - bleeding patients in surgery & trauma cases with platelets < 75,000/uL - bleeding patients with thrombocytopathy - active bleeding with thrombocytopenia (DIC)

Single Donor Platelet (SDP)

At least 3.0 x 1011 platelets 5 days (closed system). 24 hours (open system) 20-24C with continuous agitation Volume: 200-400 mL Increases platelet count to 30,000-60,000/uL Indication: platelet refractoriness (HLA alloimmunization)

Platelet Leukoreduced
Stored at 20-24 C for 5 days must contain less than 8.3 x 105 leukocytes for Random Donor 5 x 106 leukocytes for Single Donor Indication: -prevention of febrile nonhemolytic reactions

Granulocyte concentrate
Prepared by apheresis from a single donor Steroids given prior to procedure & exposed to Hydroxyethyl starch At least 1.0 x 1010 granulocytes Contain WBC, platelets, RBC (10%), plasma Volume: 200-600 mL 20-24C without agitation within 24 hours ABO & Rh, crossmatch compatible

 Indications: - severe neutropenia (<500/uL) - patients unresponsive to antibiotic therapy for 48 hours

Seldom used - newer antibiotics - use of G-CSF/GM-CSF - severe complications & difficult monitoring

Plasma and plasma derived components

Fresh Frozen Plasma

Contains labile & non-labile clotting factors, 90% water, 6-8% proteins, small amounts of carbohydrates & lipids Frozen w/in 8 hrs if the anticoagulant used was CPD, CD2D, or CPDA-1 and 6 hrs if preserved using ACD 1 year: < -18C 7 years: -65C Thawed: at 37C maintained at 1-6 C (< 24 hrs)

 Prepared within 8 hours of WB collection by centrifugation & separating 200-250 ml plasma ABO compatible Increases factor by 20-30% Indications: - Coagulation deficiencies - Liver disease - DIC - Massive transfusion

Cryoprecipitate
Cold-precipitated concentration of factor VIII Prepared from FFP thawed slowly between 16 C Contains > 80 U AHF activity & > 150 mg fibrinogen Other significant factors include Factor XIII, vWF, and fibronectin.

Fresh Frozen Plasma

Slow thawing @ 1-6C Centrifuge (hard spin) 10-25 ml of plasma with white precipitate (Cryoprecipitate)

Refrozen @ < -18C

 Frozen: 1 year at <-18C Pooled: maximum of 4 hours Thawed: at 37C 20-24C until transfused (w/in 6 hours) Indications: Classic hemophilia von Willebrands disease Factor XIII deficiency Hypofibrogenemia It should not be used to treat : Classic hemophilia or von Willebrands disease if virusinactivated or recombinant factor preparations are available.

Plasma derivatives

Factor VIIa Concentrate

Produced by recombinant DNA technology and has been proven in patients with hemophilia A or inhibitors to factor VIII and in patients with congenital factor VII deficiency.

Factor VIII Concentrate

Recombinant FVIII using DNA technology Large volumes of pooled plasma - pasteurization - solvent & detergent treatment - monoclonal purification For treatment of Hemophilia A and has replaced cryoprecipitate as the product of choice. 1U FVIII/kg BW increases by 2% 1-6 C

Factor IX Concentrate
3 forms: 1) Prothrombin complex concentrate - vitamin K dependent factors (II, VII, IX, X) - prepared from large volumes of pooled plasma by absorbing the factors using barium sulfate and aluminum hydroxide. 2) Factor IX concentrate - manufactured by monoclonal Ab purification and is less thrombogenic than prothrombin complex concentrates. - approximately 20-30% Factor IX

Factor IX Concentrate
3) Recombinant factor IX (rFIX) -produced in Chinese hamster ovary cell line and thought to transmit human infectious disease - still controversial with regards to reliability of the product

Immune Serum Globulin

Concentrate of plasma gamma globulins in aqueous solution Prepared from pooled plasma (cold fractionation) Intravenous (IV): more IgG : 1 year Intramuscular (IM): 3 years

 Indications: - immunodeficiency diseases - passive antibody prophylaxis against hepatitis & herpes - ITP - post transfusion purpura - HIV- related thrombocytopenia - neonatal alloimmune thrombocytopenia

Other Plasma Derivatives

Factor XIII concentrates Rho (D) Immune Globulin Normal Serum Albumin (NSA) Antithrombin III concentrates

Synthetic Volume Expanders

Two Categories:
1) Crystalloids - useful in burn patients because of their ability to rapidly cross the capillary membrane and increase the plasma volume. - Ringers lactate (NaCl, K+, Ca++, lactate ions and normal isotonic saline (NaCl) 2) Colloids - are used as volume expanders in hemorrhagic shock and burn patients - dextran and HES

Summary
Whole blood Packed rbc leukocyte poor - washed prbc - Frozen, thawed, deglycerolized Platelet concentrate single donor - random donor Granulocyte concentrate

* All these components can be irradiated

 Fresh frozen plasma Cryoprecipitate Other plasma derivatives - Factor VIII - Factor IX - Factor XIII - Immune Serum Globulins - Plasma Protein Fraction - Albumin

Thank You!