Hema: Case 4

Question 1

BASIS OF CLASSIFYING BLOOD INTO GROUPS
BLOOD GROUPS OF ABO & Rh SYSTEM

Answer 1

● ABO System: Type A, B, AB, O
● Rh System: Rh-positive, Rh-negative

Question 2

Antigens (agglutinogens) and antibodies (agglutinins) of each group:

ABO System

Answer 2

Genotype, BT, Agglutinogen, Agglutinin

OO — O (47%) — none — anti-A, anti-B
OA/AA — A (41%) — A — anti-B
OB/BB — B (9%) — B — anti-A
AB — AB (3%) — A and B — none

Question 3

Rh System

There are six common types of Rh antigens, each of which is called an Rh factor.

Answer 3

○ These types are designated C, D, E, c, d, and e.
○ A person who has a C antigen does not have the c antigen, but the person missing the C antigen always has the c antigen.
○ The same is true for the D-d and E-e antigens.

Question 4

What is widely prevalent in the population and considerably more antigenic than the other Rh antigens?

Answer 4

D antigen

Question 5

What does it mean to have D antigen?

Answer 5

Therefore, anyone who has this type of antigen is said to be Rh-positive, whereas a person who does not have D antigen is said to be Rh-negative.

Question 6

● However, it must be noted that even in Rh-negative people, some of the other Rh antigens can still cause transfusion reactions, although the reactions are usually much milder.

● About 85% of all white people are Rh-positive and 15%, Rh-negative.
○ In American blacks, the percentage of Rh-positives is about 95, whereas in African blacks, it is virtually 100%.

Question 7

GENETIC DETERMINANTS OF BLOOD GROUPS

Answer 7

ABO System
● Two genes, one on each of two paired chromosomes, determine the O-A-B blood type.
○ These two genes are allelomorphic genes that can be any one of three types but only one type on each chromosome: type O, type A or type B.
● The type O gene is either functionless or almost functionless, so that it causes no significant type O agglutinogen on the cells.
● Conversely, the type A and type B genes do cause strong agglutinogens on the cells.
● The six possible combinations of genes are OO, OA, OB, AA, BB and AB.
○ These combinations of genes are known as the genotypes, and each person is one of the six genotypes.
○ A person with genotype OO produces no agglutinogens, and therefore the blood type is O.
○ A person with genotype OA or AA produces type A type agglutinogens and therefore, has blood type A.
○ Genotypes OB and BB give type B blood, and genotype AB gives AB blood.

Rh System
● Two highly homologous genes on the short arm of chromosome 1 encode the non-glycosylated polypeptides that express the Rh antigens.
● One gene, designated RhD, determines the presence of a membrane-spanning protein that confers D activity on the red cell.
● At the locus immediately upstream, the gene RhCE determines the C, c, E, and e antigens; its alleles are RHCe, RHCE, RhcE, and Rhce.

Question 8

ORIGIN OF ANTIBODIES

ABO System

Answer 8

● The agglutinins are gamma globulins, as are other antibodies, and are produced by the same cells that produce antibodies to any other antigens.

● Most of them are IgM and IgG immunoglobulin molecules.

● But why are these agglutinins produced in people who do
not have the respective agglutinogens in their rbc? The answer to this is that small amounts of group A and B antigens enter the body in food, in bacteria, and in other ways, and these substances initiate the development of the anti-A and anti-B agglutinins.
○ For instance, infusion of group A antigen into a recipient having a non-A blood type causes a typical Immune response with formation of greater quantities of anti-A agglutinins than ever.

● Also, the neonate has few, if any, agglutinins, showing that agglutinin formation occurs almost entirely after birth.

Question 9

ORIGIN OF ANTIBODIES

Rh System

Answer 9

● When red blood cells containing Rh factor are injected into a person whose blood does not contain the Rh factor — that is, into an Rh-negative person — anti-Rh agglutinins develop slowly, the maximum concentration of agglutinins occurring about 2 to 4 months later.

Question 10

Significance of Classifying Blood into Groups

Answer 10

● For purposes of blood transfusion, it is important to know the basics of the ABO and Rh systems.

● However, knowledge of blood group systems is also of biochemical, genetic, immunologic, anthropologic, obstetric, pathologic, and forensic interest.

Question 11

● A portion of red blood cells with unknown blood group antigens is mixed with anti-A agglutinin, another portion with anti-B agglutinin, and another with anti-D.

● After several minutes, the mixtures are observed. If the red blood cells have become clumped or agglutinated, there is an antigen-antibody reaction.

● This is forward typing and determines the antigens present on red cells using antisera.

● The following lists the presence or absence of agglutination of the different blood groups:

Answer 11

O — (-) both anti-A sera and anti-B sera
A — (+) anti-A sera
B — (-) anti-B sera
AB — (+) both anti-A, anti-B sera
Rh-positive — (+) anti-D
Rh-negative — (-) anti-D

Question 12

Reverse typing makes use of reagent red cells of known blood groups to determine the presence of corresponding antibodies in unknown serum as indicated by agglutination of the red cells.

Answer 12

Blood type — reagent A cells — reagent B cells
O — (+) — (+)
A — (-) — (+)
B — (+) — (-)
AB — (-) — (-)

Question 13

BLOOD GROUPS IN OTHER BLOOD GROUP SYSTEMS THAT ARE SIGNIFICANT IN BLOOD TRANSFUSION

Answer 13

● MNS System: M,N, S, s, U antigens
● Kell System: K, k, Kpa, Kpb Jsa, Jsb
● Duffy System: Fya, Fyb
● Kidd System: Jka, Jkb
● Lutheran System: Lua, Lub
● Lewis System: Lea, Leb
● P System: P1, P, Pk

Question 14

DETERMINE HOW TO RULE OUT PATERNITY BASED ON THE ABO BLOOD GROUP SYSTEM

● To help students understand how to rule out paternity through ABO blood grouping, ask them to perform an exercise wherein there is a child whose father’s paternity is in question (or the father refuses to acknowledge the child as his)

● Example:
Mother : Type AB
Child : Type O
Putative Father : Type B

Answer 14

Procedure:

Mother: Type AB (phenotype: AB ; genotype: AB)
Child: Type O (phenotype: O ; geno: OO)
Putative Father: Type B (phen: B ; geno: BB/BO)

Possible children: AB & B (if mother is AB, father is BB)

Possible children: AB, B, A (if mother is AB, father is B)

Conclusion: Because the child is Type O, it is impossible for the putative father to be the father of this child, since a Type O blood cannot result from this union.

Question 15

PRINCIPLES AND PROCEDURES IN DONOR SELECTION AND SCREENING

Criteria for Donor Selection
A. Target groups for blood donation
● Healthy men and women with the following characteristics should be considered “potential blood donors”:

Answer 15

Age: Between 16-65 yrs old (parental consent required of under 18)

Weight: at least 50 kg (450 ml donation)
at least 40 kg (250 ml donation)

Pulse rate: regular rhythm, 50-100 beats/min

Blood pressure: 90-160 mmHg, systolic and 60-100 mmHg diastolic

Hemoglobin: 125 g/L (12.5 g/dl)

Question 16

PRINCIPLES AND PROCEDURES IN DONOR SELECTION AND SCREENING

Criteria for Donor Selection
B. Donor Temporary Deferment
● For the protection of donors and recipients, donors coming with the following conditions should be deferred for the stated duration:

Answer 16

Pregnant women: Defer until 9 months after child birth or 3 months after weaning, whichever is longer

Acute febrile illness: Defer until fully recovered, or about 2-3 weeks after febrile episode

Previous donation: At Least 3 months after 450 ml Atleast 6-8 weeks after 250 ml

Major operation (incl. dental surgery) or blood transfusion: Defer until 12 months after operation or transfusion

Skin lesions at venipuncture site: Defer until after skin lesion have completely healed

Past exposure to unhygienic, ear holing, needle puncture, etc.: Defer for 1 year after incident

Past exposure to a sexual partner or close household contact with HIV/AIDS or hepatitis: Defer for 1 year after exposure

All persons who have been diagnosed or treated for malaria: Defer for 3 years after the cessation of s/s or treatment for malaria

Recent alcohol intake: Defer for 12 hours after the last alcohol intake

Question 17

● The period of deferment shall also vary according to the type of vaccine and date when this was received.

Answer 17

Live attenuated vaccines:
1. Measles, oral polio, mumps, BCG — 2 weeks
2. German measles — 1 month
3. Rabies — 1 year

Killed vaccines and toxoids: DPT, injectable polio, hepatitis B — May donate anytime if without vaccine-associated symptoms like fever

Question 18

● Acceptance or deferral of donation depends on the underlying disease for which a drug is taken except for those listed below.

● The severity of the medical condition for which the drugs are being taken must also be considered.

Answer 18

Antibiotics other than anti-TB drugs: If condition not severe, may donate anytime

Anti-TB drugs: Until tuberculosis is completely cured

Aspirin and piroxicam: May donate anytime if blood is not used for its platelets

Highly allergenic drugs like penicillin:
May donate after meds are stopped for 1 day

Contraceptive pills, Depo: May donate anytime

Other drugs for symptomatic treatment: Generally, may donate anytime

Question 19

● For the protection of the donor and recipient, persons with the following conditions shall not be allowed to donate blood at any time absolutely necessary:

Answer 19

○ Cancer

○ Cardiac disease like arrhythmias, CHF, etc.

○ Severe lung diseases like complicated asthma with bronchiectasis or atelectasis

○ Viral hepatitis or jaundice of unknown origin and other severe liver diseases like cirrhosis

○ Use of prohibited drugs (past or present)

○ High risk sexual behavior or continuing exposure to persons with hepatitis, HIV/AIDS and other sexually transmitted diseases including inmates of mental institution and prisons

○ High risk occupations like prostitution

○ Sexually transmitted disease (past or present)

○ Prolonged bleeding

○ Unexplained weight loss of more than 5 kg over 6 months

○ Chronic alcoholism

Question 20

Donors in occupations such as pilots, flight stewardesses, drivers and occupations needing strenuous physical exertion may donate provided they refrain from work for at least:

Answer 20

may donate provided they refrain from work for at least 24 hours after donation

Question 21

List the Screening Tests performed on Donor and Donor’s Blood
Donor Screening (step-by-step)

Answer 21

1. Interview and Physical examination
2. Hemoglobin determination, Blood typing
3. Disease Screening
Anti-HIV 1 and 2: Enzyme Immunoassay (EIA), Particle Agglutination (PA)
HBsAg: EIA, Immunochromatography assay
Anti-HCV: PA EIA
Serologic test for Syphilis: Rapid Plasma Reagin Card test VDRL Slide test
Detection of malarial parasite: Quantitative buffy coat method malarial smear

Question 22

Recognize a Donor Reaction and state the Recommended Management for each Donor Reactions:

Answer 22

● Lightheadedness weakness, tingling sensation, palpitations
○ commonly attributed to anxiety or hypoglycemia
○ prevention / management:
■ Reassuring conversation
■ Try any of the following
1. elevate donor’s feet
2. apply cold, wet towels to neck and forehead
3. have donor breathe into paper bag
4. provide juice even before donation
■ Last resort: Discontinue donation

● Fainting
○ commonly attributed to anxiety or hypoglycemia
○ prevention / management:
■ Discontinue donation
■ If necessary, administer glucose solution
■ Provide juice Even before donation
■ Position donor in a place protected from possible fall

● Convulsion
○ commonly attributed to anxiety or underlying disease
○ prevention / management:
■ D/C donation
■ Elevate feet
■ Restrain gently to prevent injury
■ Maintain airway
■ Reassure after recovering consciousness
■ Inform about possible involuntary loss of
control of urine and stool during convulsion

● Hematoma
○ commonly attributed to very fragile veins, unskilled
○ prevention/management
■ D/C if large
■ Apply pressure to site for at least 5 mins
■ Apply cold packs
■ Reassure donor

Question 23

PROCEDURE FOR PRE-TRANSFUSION TESTING OF DONOR AND PATIENT SPECIMENS, CROSSMATCH PROCEDURES, AND ANTIBODY SCREENING

PRE-TRANSFUSION TESTING (3 parts)

Answer 23

A. Crossmatching

B. Major and Minor Crossmatch Tests

C. Antibody Screening

Question 24

A. Crossmatching

Answer 24

● The terms compatibility test and crossmatch are sometimes used interchangeably; they should be clearly differentiated.

● A crossmatch is only part of a compatibility test.

Question 25

Compatibility testing consists of:

Answer 25

○ (1) review of patient’s past blood bank history and records;
○ (2) ABO and Rh grouping of the recipient and donor;
○ (3) antibody screening of the recipient’s and donors serum; and finally
○ (4) the crossmatch.

Question 26

Two main functions of the crossmatch test can be cited:

Answer 26

○ It is a final check of ABO compatibility between donor and patient.

○ It may detect the presence of an antibody in the patient’s serum that will react with antigens on the donor red blood cells but that was not detected in antibody screening because the corresponding antigen was lacking from the screening cells.

Question 27

ABO AND Rh COMPATIBILITY

Answer 27

Recipient’s Blood type — Donor’s blood type
O — O
A — O: s ; A: yes
B — O: s ; B: yes
AB — O, A, B: s ; AB: yes

D- — D-: yes ; D+: E
D+ — D- & D+: yes

S = substitute as packed rbc or wash to eliminate antibodies
E = only under extreme emergency conditions, especially if the recipient is a young female

Question 28

B. Major and Minor Crossmatch Tests

Answer 28

Historically, crossmatch testing procedures have been divided into two parts:
○ the major crossmatch test, consisting of mixing the patient’s serum with donor red cells: and
○ the minor test, consisting of mixing the donor’s plasma with patient red cells.

● This detects ABO incompatibility and clinically significant unexpected antibodies.

● As the names imply, the major test is much more critical for ensuring safe transfusion than the minor test.

● The minor crossmatch test has been completely eliminated in most blood banks because donor samples are screened beforehand for the more common antibodies.

Question 29

C. Antibody Screening

Answer 29

● The patient’s serum or plasma must be tested for unexpected antibodies.

● The object of the antibody screening test is to detect as many clinically significant antibodies as possible. In general, the term clinically significant antibodies refers to antibodies that are reactive at 37C and/or in the antihuman globulin test and are known to have caused a transfusion reaction or unacceptably short survival of the transfused red cells.

● Antibodies regarded as always being potentially clinically significant are: ABO, Rh, Kell, Duffy, Kidd, SsU.

● Antibodies that may sometimes be clinically significant are: Lea. MN, P1, Lutheran and Cartwright.

Question 30

BLOOD COMPONENTS

Answer 30

● Whole blood (450 ml/250 ml)
● Red blood cells/Packed rbc/Packed cells (350 ml; hct = 55 — 70%)
● Platelet concentrate (60 ml; at least 5.5 x 1010 platelets)
● Fresh Frozen Plasma (240 ml/60 ml)
● Washed red blood cells
● Cryoprecipitate (30 ml)
● Granulocytes (300 ml) (1.0 X 1010)
● Blood derivatives (commercially available)

Question 31

Whole blood (450 ml/250 ml)

Answer 31

● Composition: all cellular and plasma components deficient in active platelets, granulocytes and labile clotting factors

● Indication: actively bleeding patient (more than 25-30% blood loss or about 2 liters) with impending hemorrhagic shock

● C/I: anemia without hypovolemia or active bleeding when blood volume can be adequately replaced by volume expanders coagulation factor deficiencies

● Storage: 1-6°C
○ CPD — 21 days
○ CPDA1 — 35 days
○ CPDA2 or SAG-M — 42 days

Question 32

Red blood cells/Packed RBC/Packed cells (350 ml; hct = 55 — 70%)

Answer 32

● Cellular products remaining after removal of most of plasma by sedimentation or centrifugation of WB

● Contains rbc, platelets and leukocytes major indication: patients with symptomatic deficit of O2-carrying capacity (eg: severe or chronic anemia not corrected by iron, vit. B12 or folic acid)

● A standard unit raises hot level by 3%

● Stored like WB (whole blood)

Question 33

Platelet concentrate (60 ml; at least 5.5 x 1010 platelets)

Answer 33

● Platelets suspended in a small quantity of plasma separated from WB within 6 hours post-donation before refrigeration

● Indications:
○ treatment or prevention of bleeding due to deficient platelet number (<20T) or function
○ patients about to undergo surgery with platelets <50T/cumm
○ long-term supportive treatment of conditions with bone marrow depression

● One unit usually increases platelet count by 5 — 10T/cumm

● Not usually effective in ITP

● Stored at room temp in continuous agitation (72 hours)

● By apheresis: 3.0 x 1011 platelets
○ 5 days at room temp (closed system); 1 day (open system) (constant, gentle agitation)

Question 34

Fresh Frozen Plasma (240 ml/60 ml)

Answer 34

● The non-cellular fluid portion of anticoagulated blood which has been extracted from a single donor unit within 8 hours post-donation and rapidly frozen to —30°C

● Contains plasma proteins and all coagulation factors plus complement

● Indications:
○ control or prevention of bleeding in multiple
coagulation defects (eg. Liver disease, DIC)
○ those requiring factors V and VIII but concentrates
not available
○ TTP

● One unit will increase level of any clotting factor by 2-3 % to be used within 6 hrs after thawing (in water bath)

● Stored at —18 to -30°C (12 months)

Question 35

Washed red blood cells

Answer 35

● RBC which has been washed with compatible solution to reduce more than 95% leukocytes and plasma proteins

● Used only for those requiring repeated transfusions who develop febrile nonhemolytic transfusion reactions

● Stored at 1-6°C (24 hours)

● Frozen deglycerolized RBC: for rare blood,
autotransfusion
○ may be stored at -65 C (10 yrs)

Question 36

Cryoprecipitate (30 ml)

Answer 36

● The cold insoluble portion of plasma after FFP has been thawed between 1-6°C

● Contains coagulation factors VIII, XIII, fibrinogen and fibronectin and VWF (200 — 250 mg)

● Indications:
○ acute hemorrhage or anticipated surgery in
hemophilia A patients if freeze dried factor VIII not
available
○ vWF disease
○ prophylaxis for factor XIll or fibrinogen deficiency

● Stored at -30°C or lower (12 months)

● Cryosupernatant: residual plasma refrozen after removal of cryoprecipitate; same as FFP except VIII

Question 37

Granulocytes (300 ml) (1.0 X 1010)

Answer 37

● Usually obtained using cell separator machine for 3 — 4 hours yielding from 55 -300 X 109 granulocytes

● Effectiveness still under investigation

● Used as supportive therapy for those with neutropenia (<0.5 X 109/l) and infections not responsive to antibiotic therapy

● 12—24 hrs at room temp; no agitation

Question 38

Blood derivatives (commercially available)

Answer 38

● Albumin
● Factor VIII concentrate
● Factor IX
● Immunoglobulins

Question 39

Whole blood
Characteristics, Approximate Volume, Shelf-Life, Indications, and Comments

Answer 39

Characteristics: RBCs and plasma; platelets not viable after 24-hour storage. Labile clotting factors significantly decreased after 2 days of storage. Hct 36-44% (dilution by anticoagulant); blood 450 mL. CPD or CPDA-1. Anticoagulant 63 mL. 1-3 x 109 leukocytes.

Approximate Volume: 520 mL

Shelf-Life:
CPD: 21 days at 1-6oC.
CPDA-1: 35 days at 1-6oC.

Indications & Comments:
Massive transfusion where both red cell mass and plasma volume are required active brisk bleeding. The flow characteristics are rapid (RBCs in additive solution may be an alternative). Transfusion of whole blood always have to be ABO group specific. One unit will raise Hb by 1 g in an average size adult.

Question 40

Red blood cells
Characteristics, Approximate Volume, Shelf-Life, Indications, and Comments

Answer 40

Characteristics: Packed RBCs with reduced plasma volume; WBCs, platelets, as for whole blood. Hct 70-80%.

Approximate Volume: 260 mL

Shelf-Life: As whole blood.

Indications & Comments: Symptomatic anemia in normovolemic patients; Patients who cannot tolerate excessive volume. Flow characteristics are slower than whole blood or RBCs in additive solution. Crystalloids or colloids are used to increase flow. One unit will increase Hb by 1 g in an average size adult. 10 mL/kg in infants will raise Hb by 3 g.

Question 41

Red blood cells in additive solution (adenine-saline)

Answer 41

Characteristics: RBCs with reduced plasma volume and an additional 100mL of additive solution. WBCs and platelets as for whole blood.

Approximate Volume: 340 mL

Shelf-Life: 42 days at 1-6oC.

Indications & Comments: Same as whole blood or packed RBCs. Rapid flow rates may be achieved. No solutions other than isotonic saline may be added. Group O uncrossmatched units can be used for emergency transfusion (e.g. trauma). Small volume (10 mL/kg) transfusions–no problem in premature infants.

Question 42

Washed red blood cells

Answer 42

Characteristics: RBCs, no plasma. Hct 70-80%. Washing in saline removes 98% of plasma. Up to 20% loss of red cells.

Approximate Volume: 180 mL

Shelf-Life: 24 hours at 1-6oC.

Indications & Comments: Prevention of recurrent or severe allergic reactions. Neonatal or intrauterine transfusion. Prevention of anaphylactic reactions in IgA-deficient patients. Not indicated for leukoreduction requiring 3-log removal of WBCs.

Question 43

Frozen deglycerolized red blood cells

Answer 43

Characteristics: RBCs. no plasma. Hct usually 70-80% once reconstituted in saline. Removes >90% of WBCs (<2 logs). Up to 20% of red cells may be lost.

Approximate Volume: 250 mL

Shelf-Life: 10 years at -65oC to -200oC.
24 hours at 1-6oC after washing.

Indications & Comments: Long-term preservation of RBC units with rare phenotype or autologous RBC units. Alternative to CMV-seronegative units in emergencies. Decreases febrile transfusion reactions. Not indicated for 3-log leukoreduction. Also as per washed RBC units.

Question 44

Leukocyte-reduced red blood cells (3 log)

Answer 44

Characteristics: RBCs; less than 5 x 106 WBCs; at least 85% of RBCs in original unit

Approximate Volume: Similar to original unit.

Shelf-Life: Similar to original unit when closed system used.

Indications & Comments: 3-log leukocyte-reduction decreases risk of alloimmunization to HLA antigens on leukocytes, decrease febrile nonhemolytic transfusion reactions, reduces risk of cytomegalovirus infection, decreases immunomodulation, and may decrease the risk of prion transmission in B lymphocytes. It does not prevent GVHD. Universal leukoreduction of all cellular products may become the standard of care in the near future.

Question 45

Two-unit red blood cells, apheresis

Answer 45

Characteristics: 2RBC is divided into two separate RBC units of equal volume; similar to packed RBCs; Hct 55%.

Approximate Volume: 320 mL

Shelf-Life: 1 year at 1-6oC.

Indications & Comments: Same indications as packed RBCs.

Question 46

Random-donor platelet concentrate

Answer 46

Characteristics: Platelets (at least 5.5 x 1010); 50-70 mL of plasma to maintain pH greater than 6.2 0.5-1.0 x 108 leukocytes. Less than 0.5 mL of RBCs.

Approximate Volume: 50-70 mL

Shelf-Life: 5 days, at 20-24oC with constant gentle agitation. 4 hours after pooling.

Indications & Comments: Bleeding due to quantitative or qualitative platelet disorders. Prophylaxis in severely thrombocytopenic patients with counts below 5000-10,000/ uL; one unit results in an average post-transfusion platelet increment of 5000 in a 70-kg adult. Dose is one unit of platelets per 10 kg, including children (a pool of units in an adult results in post-transfusion increment of approximately 30,000). Expected corrected count increments of 7500 at 10 minutes to 1 hour.

Question 47

Cryopoor plasma

Answer 47

Characteristics: Component remaining after cryoprecipitate is prepared. Minimal concentrations of fibrinogen, factor VIII, and vWF.

Approximate Volume: 200 mL

Shelf-Life: Same as FFP.

Indications & Comments: Used primarily in patients with hemolytic uremic syndrome/thrombotic thrombocytopenic purpura.

Question 48

Cryoprecipitate

Answer 48

Characteristics: 80 units of factor VIII; >150 mg fibrinogen, 40-70% of vWF and 20-30% of factor XIII present in the initial unit of FFP. It does not contain factor V.

Approximate Volume: 10-15 mL

Shelf-Life: 1 year at -18oC or below. 6 hours after thawing.

Indications & Comments: Congenital or acquired deficiencies of fibrinogen, and factor XIII deficiency. Use in vWF and hemophilia A when virus-inactivated factor concentrates are not available. It may be beneficial in bleeding due to uremic platelet dysfunction not responding to desmopressin (DDAVP), estrogens, or an increase in the hematocrit to 30oC. One unit will raise fibrinogen by 5 mg/dL in an average size adult. Usual dose is 1 unit per 10 kg.

Question 49

Factor VIII

Answer 49

Characteristics: It is available in several degrees of purity. All products are lyophilized. (a) VIII (1-10% factor VIII per gram of protein) and (b) high-purity factor VIII (immunoaffinity column), >90%factor VIII per gram of protein) plasma-derived concentrates are prepared by fractionation of pooled donor plasma. Contents of vWF also vary according to the preparation. Pasteurization or S/D treatment is used for viral inactivation. Some manufacturers add viral inactivation to eliminate parvovirus B19 and hepatitis A virus. (c) Recombinant factor VIII; contains trace amounts of mouse, hamster, and bovine protein. Half-life of factor VIII is 12-18 hours.

Approximate Volume: 25 mL of sterile diluent for reconstitution

Shelf-Life: 2 years at 2-8oC.

Indications & Comments: Moderate to severe hemophilia A. Dost intervals, and duration of therapy will depend on the therapeutic or prophylactic levels desired, which will vary according to the seriousness and organ affected by bleeding, or the type of surgical procedure. Dose is calculated by multiplying plasma volume in milliliters times the desired increment in percent, divided by 100. Patients with high-level inhibitors to favtor VIII may require treatment with continuous infusions of factor VIII concentrates, porcine factor VIII, factor VIIa, or factor IX concentrates, plasmapheresis, or immunosuppressants. One plasma-derived product (antihemophilic factor/vWF complex) has been approved for the treatment of vWD, and may be effective in 95% of patients. When used in high doses, intermediate-purity concentrates may result in marked elevations of fibrinogen and positive DAT and potentially in hemolysis because of anti-A or anti-B antibodies.

Question 50

Antithrombin III concentrate

Answer 50

Characteristics: Antithrombin, prepared from pooled human plasma by a modified cold ethanol fractionation, and pasteurized for viral inactivation. Half-life is 2.5 days.

Approximate Volume: As per manufacturer directions

Shelf-Life: 2 years at 2-8oC.

Indications & Comments: Treatment or prophylaxis of thrombotic events in patients with congenital antithrombin deficiency. Its use has been reported in various other conditions including DIC, heparin resistance, sepsis, and perioperatively to prevent DVT and pulmonary embolism. Once adequate dosing is established by monitoring peak and trough levels of antithrombin, it is administered every 24 hours.

Question 51

Albumin

Answer 51

Characteristics: 5 g/dL
96% albumin, 4% other plasma proteins; prepared by cold ethanol fractionation; pasteurized at 60oC for 10 hours. 5% albumin isosmotically and oncotically equivalent to plasma). Half-life is 16 hours.

Approximate Volume: 250-500 mL

Shelf-Life: 5 years at 2-10oC.

Indications & Comments: Indications are controversial. It increases colloid-oncotic pressure maintaining blood volume transiently. Hemolysis has been reported to occur when it is diluted in water and infused in the same line as RBCs. Recent studies would indicate adverse results when used in critically ill, trauma, or elderly patients, compared to patients in whom albumin was not used. These results need confirmation. Contraindicated in dehydrated patients. Flushing, urticaria, chills, fever, and headache may occur. Pediatric dose is 10-20 mL/kg.

Question 52

Plasma protein fraction

Answer 52

Characteristics: 5 g/dL. Contains 83% albumin and 17% globulin (⍺ and β).

Approximate Volume: 25-500 mL

Shelf-Life: 3 years below 30oC.

Indications & Comments: Similar to albumin. Hypotension may occur when given at rates over 10 mL/min (Hageman factor activation and/or bradykinins, especially where pulmonary vasculature is bypassed).

Question 53

Immune globulin, intravenous

Answer 53

Characteristics: Mostly iGG antibodies (>90%); traces of IgA and IgM antibodies. Prepared from pooled human plasma by cold ethanol fractionation (effluent III). Recently S/D treatment has been added to the manufacturing process. 1 g/10 mL. Half-life is 21 days.

Approximate Volume: 10-200 mL

Shelf-Life: 3 years at 2-8oC.

Indications & Comments: Primary humoral immunodeficiency, ITP, bone marrow transplant, and pediatric HIV infection. More recently it has gained acceptance in the treatment of Guillain-Barre syndrome, and other conditions. There have been reports of acute renal failure complicating IVIG therapy, due to the sucrose used as stabilizer by some manufacturers. IVIG administration may result in positive DAT and occasional hemolysis, owing to the presence of alloantibodies. Additionally it may make interpretation of CMV seroconversion difficult by passive transfer of antibodies to CMV, usually of the IgG type.

Question 54

Rh immune globulin

Answer 54

Characteristics: IgG anti-Rho (D). By convention, a full dose is 300 μg (820 IU) and a minidose is 50 μg (137 IU).

Approximate Volume: 1 mL

Shelf-Life: 11⁄2 years at 2-8oC.

Indications & Comments: Prevention of Rh alloimmunization of Rh (D)-negative individuals exposed to the D antigen; primarily used in Rh-negative pregnant women to prevent hemolytic disease of the newborn.

Question 55

Fibrin sealant

Answer 55

Characteristics: Fibrinogen (cryoprecipitate, total protein 100-130 mg/mL), human thrombin (500 IU/mL), aprotinin (3000 KIU/mL) and CaCl.

Approximate Volume: 1, 2, 4, and 10 mL

Shelf-Life: 2 years at 2-8oC.

Indications & Comments: Topical application under direct visualization. As an adjunct to hemostasis in cardiopulmonary bypass surgery, for the sealing of anastomoses, in the closure of temporary colostomies, for the treatment of spleen injuries, and as an adjunct to surgical methods of hemostasis.

Question 56

Factor IX

Answer 56

Characteristics: Plasma-derived and recombinant proteins are available: (a) Factor IX complex: contains in factors II, VII, IX, X, and other proteins. (b) Factor IX, human, purified by immunoaffinity chromatography from pooled human plasma. Contains traces of other proteins. Half-life is 22 hours. (c) Recombinant factor IX: recovery is approximately 30% lower than plasma-derived factor IX. Half-life is approximately 18 hours.

Approximate Volume: 25 mL of sterile diluent for reconstitution

Shelf-Life: 2 years at 2-8oC.

Indications & Comments: Plasma-derived factor IX complex is used to treat hemophilia B and patients with inhibitors to factor VIII or IX. The prothrombotic effect of factor IX concentrates is due to the presence of activated factors II and X, which bypass factor VII or IX and have a long half-life leading to build-up after repeated administrations. This effect may be more prominent in patients with liver disease and associated with a relative deficiency of antithrombin, which may result in thrombosis and DIC.
High-purity and recombinant factor IX are used in the treatment and prophylaxis of bleeding in patients with hemophilia B.

Question 57

STATE THE INCREMENTAL INCREASE OF THE FOLLOWING:

Answer 57

A. HEMATOCRIT FOLLOWING TRANSFUSION OF 1 UNIT PACKED RED CELLS

B. PLATELET COUNT FOLLOWING PLATELET TRANSFUSION (Expected incremental increase incorporated in blood component data)

Question 58

DESCRIBE THE PROCEDURE AND REQUIREMENTS FOR INFUSION OF BLOOD OR ITS COMPONENTS

BLOOD ADMINISTRATION

Answer 58

● Blood must be administered properly for patient safety.

● The proper identification of the patient, the patient’s blood specimen, and the blood unit for transfusion are essential.

● Careful identification procedures prevent a major cause of transfusion-related deaths and acute hemolytic transfusion reactions.
○ The identification process begins with proper identification of the patient; that is, asking patients to state or spell their name while you read their armband.
○ A patient identification label is prepared at the bedside after the specimen is drawn. This prevents an empty specimen tube from being labeled with one patient’s name and potentially being used for the collection of specimens from another patient.
○ The labels are applied to the specimen tubes before leaving the bedside to avoid labeling the wrong tube.

● Proper identification is carried out in the laboratory as work lists are drafted.

● Another clerical check is performed as blood is issued from the blood bank.

● The final clerical check is performed at the patient bedside when the nurse uses the patient armband to compare the patient identification to the patient crossmatch and issuance tags attached to the components to be transfused.

● The patient with difficult veins should have the intravenous device in place before the blood is issued from the transfusion service.

● All blood components must be filtered because clots and cellular debris develop during storage.

● Blood components are infused slowly for the first 10 to 15 mins while the patient is closely observed for signs of a transfusion reaction.

● The blood components should then be infused as quickly as tolerated or, at most, within 4 hours.

● The patient’s vital signs (pulse, respiration, blood pressure, and temperature) should be monitored periodically during the transfusion to detect signs of transfusion reaction promptly.

● These signs are fever with back pain, anaphylaxis, hives or pruritus, congestive heart failure, and fever alone.

● A delayed hemolytic transfusion reaction (jaundice, decreasing hematocrit) may be diagnosed only 7 to 10 days after transfusion and thus is not considered an immediate reaction.

● Rapid transfusion, including exchange transfusion, requires blood warming because the cold blood can cause hypothermia in the patient.

● Only isotonic (0.9 percent) saline or 5 percent albumin should be used to dilute blood components, because other intravenous solutions may damage the RBCs and cause hemolysis.

Question 59

What can prevent a major cause of transfusion-related deaths and acute hemolytic transfusion reactions?

Answer 59

Careful identification procedures

Question 60

Blood components are infused slowly for the first ____________ while the patient is closely observed for signs of a transfusion reaction.

Answer 60

10 to 15 mins

Question 61

The blood components should then be infused as quickly as tolerated or, at most, within __________.

Answer 61

4 hours

Question 62

Only _____________________ should be used to dilute blood components, because other intravenous solutions may damage the RBCs and cause hemolysis.

Answer 62

isotonic (0.9 percent) saline or 5 percent albumin

Question 63

DESCRIBE SPECIAL SITUATIONS IN TRANSFUSION MEDICINE

Answer 63

DIRECT DONATIONS
● One where patient nominates the person/s from whom will be accepted for transfusion or a donor nominates the recipient of a donation
● Usually happens when a relative/frienddonates for patient
● Blood from first and second degree relatives should be irradiated prior to transfusion

HEMAPHERESIS/APHERESIS
● Procedure in which whole blood is removed from a person, anticoagulated and separated into components → the desired components are retained and the unwanted portions are returned to the donor.
● Can be used to obtain components intended for transfusion (platelets, granulocytes, plasma) or to remove pathologic elements, cells, or dissolved plasma factors in the blood (therapeutic hemapheresis)

AUTOLOGOUS TRANSFUSION
● The collection and subsequent transfusion of the patient’s own blood
● Recommended for those about to undergo elective surgery and well enough to be venesected
● Up to four 450 ml units of blood can be collected in a period of 4 weeks prior to planned surgery (every 72 hours; up to 72 hours prior to surgery)

EXCHANGE TRANSFUSION
● Replaces the antibody-coated red blood cells of a newborn infant with compatible donor cells and removes bilirubin and circulating maternal antibodies from the baby’s plasma.
● Normally, blood for exchange transfusion should be less than 5 days old.
● Blood should be less than 5 days old
● Crossmatch using mother’s serum

MASSIVE TRANSFUSION
● Complete volume replacement within 24 hours
● Composition of circulating blood changes
● Adverse effects: citrate toxicity, hypocalcemia, hypothermia, depletion of coagulation factors and platelets

Question 64

REPUBLIC ACT 7719: VOLUNTARY BLOOD DONATION

Answer 64

RA 7719: AN ACT PROMOTING VOLUNTARY BLOOD DONATION, PROVIDING FOR AN ADEQUATE SUPPLY OF SAFE BLOOD, REGULATING BLOOD BANKS, AND PROVIDING PENALTIES FOR VIOLATION THEREOF

Question 65

SECTION 1. TITLE

Answer 65

This Act shall be known as the “National Blood Services Act of 1994”.

Question 66

SECTION 2. DECLARATION POLICY

Answer 66

● In order to promote public health, it is hereby declared the policy of the State:

○ to promote and encourage voluntary blood donation by the citizenry and to instill public consciousness of the principle that blood donation is a humanitarian act;

○ to lay down the legal principle that the provision of blood for transfusion is a professional medical service and not a sale of a commodity;

○ to provide for adequate, safe, affordable and equitable distribution of supply of blood and blood products;

○ to inform the public of the need for voluntary blood donation to curb the hazards caused by the commercial sale of blood;

○ to teach the benefits and rationale of voluntary blood donation in the existing health subjects of the formal education system in all public and private schools, in the elementary, high school and college levels as well as the non-formal education system;

○ to mobilize all sectors of the community to participate in mechanisms for voluntary and non-profit collection of blood;

○ to mandate the Department of Health to establish and organize a National Blood Transfusion Service Network in order to rationalize and improve the provision of adequate and safe supply of blood;

○ to provide for adequate assistance to institutions promoting voluntary blood donation and providing non-profit blood services, either through a system of reimbursement for costs from patients who can afford to pay, or donations from governmental and non-governmental entities:

○ to require all blood collection units and blood banks/centers to operate on a non-profit basis;

○ to establish scientific and professional standards for the operation of blood collection units and blood banks/centers in the Philippines;

○ to regulate and ensure the safety of all activities related to the collection, storage and banking of blood; and

○ to require upgrading of blood banks/centers to include preventive services and education to control spread of blood transfusion transmissible diseases.

Question 67

SECTION 3. DEFINITIONS

Answer 67

● For purposes of this Act, the following terms shall mean:

○ Blood/blood product– refers to human blood, processed or unprocessed and includes blood components, its products and derivatives;

○ Blood bank/center – a laboratory or institution with the capability to recruit and screen blood donors, collect, process, store, transport and issue blood for transfusion and provide information and/ or education on blood transfusion transmissible diseases;

○ Commercial blood bank – a blood bank that exists for profit;

○ Hospital-based blood bank – a blood bank which is located within the premises of a hospital and which can perform compatibility testing of blood;

○ Blood collection unit – an institution or facility duly authorized by the Department of Health to recruit and screen donors and collect blood;

○ Voluntary blood donor – one who donates blood on one’s own volition or initiative and without monetary compensation;

○ Department – the Department of Health;

○ Blood transfusion transmissible diseases –
diseases which may be transmitted as a result of blood transfusion, including AIDS, Hepatitis-B, Malaria and Syphilis;

○ Secretary of Health – the Secretary of Health or any other person to whom the Secretary delegates the responsibility of carrying out the provisions of this Act; and

○ Walking Blood Donor – an individual included in the list of qualified voluntary blood donors referred to in Section 4, paragraph (e), who is ready to donate blood when needed in his/her community.

Question 68

SECTION 4. PROMOTION OF VOLUNTARY BLOOD DONATION

Answer 68

● In order to ensure adequate supply of human blood, voluntary blood donation shall be promoted through the following:

○ Public Education – Through an organized and sustained nationwide public education campaign by the Department, the Philippine National Red Cross (PNRC) and the Philippine Blood Coordinating Council (PBCC), as the lead agencies, other government agencies, local government units (particularly the barangays), non-governmental organizations, all medical organizations, all public and private hospitals, all health and health-related institutions, print and broadcast media as well as other sectors. The Department is hereby authorized to set aside funds and generate financial support for all sectors involved in the collection and processing of blood from voluntary blood donors through a system of reimbursement for costs for patients who can afford to pay or from donations from government and private institutions. Voluntary donors shall likewise be provided non monetary incentives as may be determined by the Department.

○ Promotion in Schools – The benefits and rationale of voluntary blood donation shall be included and given emphasis in health subjects of schools, both public and private, at the elementary, high school and college levels. The Department of Education, Culture and Sports shall also require such inclusion in its non-formal education curricula.

○ Professional Education – The Department, the PBCC, the Philippine Society of Hematology and Blood Transfusion (PSHBT), the Philippine Society of Pathologists (PSP), the Philippine Medical Association (PMA), the Philippine Association of Medical Technologists (PAMET) and the Philippine Nursing Association (PNA) are encouraged to conduct for their respective members and as part of the continuing medical education, trainings on the rational use of blood and blood products including the merits of voluntary blood donation.

○ Establishment of Blood Services Network – Blood centers shall be strategically established in every province and city nationwide within the framework of a National Blood Transfusion Service Network spearheaded by the Department, in coordination with the PNRC. The collection of blood in various areas in the community, such as schools, business enterprises, barangays, and military camps shall be promoted.

○ The Secretary shall set the standards for the scientific and professional establishment and operation of blood banks/centers and collection units. The Department shall provide training programs and technical assistance to enable communities, schools, industrial and business sites, barangays, military camps and local government units to implement their own voluntary blood donation programs.

○ Walking Blood Donors – In areas where there may be inadequate blood banking facilities, the walking blood donor concept shall be encouraged and all government hospitals, rural-health units, health centers and barangays in these areas shall be required to keep at all times a list of qualified voluntary blood donors with their specified blood typing.

Question 69

SECTION 5. NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM

Answer 69

● The Department, in cooperation with the PNRC and PBCC and other government agencies and non-governmental organizations shall plan and implement a National Voluntary Blood Services Program (NVBSP) to meet in an evolutionary manner, the needs for blood transfusion in all regions of the country.

● Funds for this purpose shall be provided by the Government through the budgetary allocation of the Department, by the Philippine Charity Sweepstakes Office (PCSO) with an initial amount of at least Twenty-five million pesos (P25,000,000), by the Philippine Amusement and Gaming Corporation (PAGCOR) with an initial amount of at least Twenty-five million pesos (P25,000,000), by the trust liability account of the Duty Free Shop (Duty Free Philippines) with an initial amount of at least Twenty million pesos (P20,000,000) and through contributions of other agencies such as civic organizations.

Question 70

SECTION 6. UPGRADING OF SERVICES AND FACILITIES

Answer 70

● All blood banks/ centers shall provide preventive health services such as education and counseling on blood transfusion transmissible diseases.

● All government hospitals, including those that have been devolved, shall be required to establish voluntary blood donation programs and all private hospitals shall be encouraged to establish voluntary blood donation programs.

● The Department, in consultation with the PSHBT and the PSP, shall also establish guidelines for the rational use of blood and blood products.

Question 71

SECTION 7. PHASE OUT COMMERCIAL BLOOD BANKS

Answer 71

AH commercial blood banks shall be phased-out over a period of two (2) years after the effectivity of this Act, extendable to a maximum period of two (2) years by the Secretary.