Transfusion

Overview :

Either whole blood or blood components can be used for transfusion. Whole blood is used exactly as it was received from the donor. Blood components are parts of whole blood, such as red blood cells (RBCs), plasma, platelets, clotting factors, immunoglobulins, and white blood cells. Whole blood is used only when needed or when components are not available. Most of the time whole blood is not used because the patient's medical condition can be treated with a blood component and too much whole blood can raise a recipient's blood pressure. High blood pressure can have medical side effects and should be avoided. Use of blood components is a more efficient way to use the blood supply, because blood that has been processed (fractionated) into components can be used to treat more than one person. Each year, more than 20 million units of blood or blood products are transfused in the United States.

Whole blood is generally used when a person has lost a lot of blood. Such blood loss can be caused by injury or surgical procedures. Whole blood is given to help restore the blood volume, which is essential for maintaining blood pressure. Whole blood is also given to ensure that the body's tissues are receiving enough oxygen. Whole blood is occasionally given when a required blood component is unavailable in isolated form.

Red blood cells are the blood component most frequently used for transfusion. RBCs are the only cells in the body that transport oxygen. A transfusion of RBCs increases the amount of oxygen that can be carried to the tissues of the body. RBCs that have been separated from the liquid plasma (packed RBCs) are given to people who have anemia or who have lost a lot of blood. Platelets are another component frequently given by transfusion. Platelets are a key factor in blood clotting. The clear fluid that carries blood cells (plasma) also contains blood-clotting factors. The platelets and plasma clotting factors are extracted from donated blood and concentrated for use. These factors are used to treat people with such clotting disorders as hemophilia. Immunoglobulins, also called gamma globulin or immune serum, are collected from plasma for use in temporarily boosting the immune capability of a patient. White blood cells (WBCs) are another infection-fighting component of the blood. White blood cells are given by transfusion only rarely.

Blood donation

Each year in the United States, about 14,000,000 pints of blood are donated. Blood collection is strictly regulated by the U.S. Food and Drug Administration (FDA). The FDA has rules for the collection, processing, storage, and transportation of blood and blood products. In addition, the American Red Cross, United Blood Services, the American Association of Blood Banks, and most states have specific rules for the collection and processing of blood. The main purpose of regulation is to ensure the quality of blood and to prevent the transmission of infectious diseases through donated blood. Before blood and blood products are used, they are extensively tested for such infectious agents as hepatitis and AIDS.

DONORS. Blood donors are questioned about their general health, their lifestyle, and any medical conditions that might disqualify them as donors. These conditions include hepatitis, AIDS, cancer, heart disease, asthma, malaria, bleeding disorders, and high blood pressure. Screening prevents blood donation by people who could transmit diseases or by people whose medical condition would place them at risk if they donated blood.

The blood pressure, temperature, and pulse of donors are taken to ensure that they are physically able to donate blood. One pint (450 ml) of blood is usually donated, although it is possible to donate smaller volumes. The average man has 10-12 pints and the average woman 8-9 pints of blood. Within hours after donating, most people have replaced the fluid lost with the donated blood, bringing their blood volume back to normal. Replacing donated blood cells and platelets can take several weeks. People with low blood pressure or anemia, and pregnant women should not donate blood or should limit the amount of blood they donate. Generally, people are allowed to donate blood only once every two months. This delay ensures the health of the donor and discourages people from selling their blood. The practice of paying donors for blood has essentially stopped. Donors who sell blood tend to have a high risk for the transmission of infectious agents.

BLOOD COLLECTION. Blood is collected from the donor by inserting a large needle into a vein in the arm. Usually, one of the larger veins near the inside of the elbow is used. A tourniquet is placed on the upper arm to increase the pressure in the arm veins and make them swell and become more accessible. Once a suitable vein is identified, the area where the needle will be inserted is sterilized by washing with soap solution or an iodine-containing antiseptic. Sometimes both are used. The donor lies on a bed or cot during the procedure, which takes about 10 minutes. Generally, an 18-gauge needle is used. This needle can easily fit into the veins and yet is large enough that the blood flows easily. Blood will sometimes clot in a smaller needle and stop flowing. Blood is collected in sterile plastic bags that hold one pint (450 ml). The bags contain an anticoagulant to prevent clotting and preservatives to keep the blood cells alive. Properly handled and refrigerated, whole blood can last for 42 days. While emphasis has been on screening of blood donors and testing of blood products before they are released for transfusion, the emphasis is beginning to shift to future techniques designed to cleanse the blood and rid it of possible pathogens or reactants.

AUTOLOGOUS TRANSFUSION. Autologous transfusion is a procedure in which patients donate blood for their own use. Patients who are to undergo surgical procedures for which a blood transfusion might be required may elect to donate a supply of blood for the purpose ahead of time. The blood is stored at the hospital for the exclusive use of the patient. This procedure assures that the blood type is an exact match. It also assures that no infection will be transmitted through the blood transfusion.

DIRECTED DONATION. Directed donors are family or friends of the patient who needs a transfusion. Some people think that family and friends provide a safer source of blood than the general blood supply. Studies do not show that directed donor blood is any safer. Blood that is not used for the identified patient becomes part of the general blood supply.

APHERESIS. Apheresis is a special procedure in which only the necessary components of a donor's blood are collected. The remaining components are returned to the donor. A special blood-processing instrument is used in apheresis. It separates the blood into components, saves the desired component, and pumps all the other components back into the donor. Because donors give only part of their blood, they can donate more frequently. For example, people can give almost 10 times as many platelets by apheresis as they could give by donating whole blood.

BLOOD PROCESSING. A sample of the donator's blood is collected at the time of donation and tested for infectious diseases. Blood is not used until the results from these tests confirm that it is safe.

BLOOD TYPING. The donated blood is typed. There are major and minor blood types, also called blood groups. The major types are classified by the ABO system. This system groups blood by two substances, called antigen A and antigen B, in the red blood cells. The four ABO blood types are A, B, AB, and O. Type A blood has the A antigen, type B has the B antigen, type AB has both, and type O has neither. These four types of blood are further sorted by the Rh factor. The Rh, or rhesus factor, is also an antigen in the red blood cells. A person who has the Rh factor is Rh positive; a person who does not have the factor is Rh negative. If a person has red blood cells with both the B and the Rh antigens, that person is said to have a B positive (B+) blood type. Blood types determine what blood a patient can receive. Often, patients are limited to receiving only blood of the same ABO and Rh type as their own. An exception is type O, which can be transfused to people of other types. Those who are Rh negative can only receive Rh negative blood (Rh positive recipients also can safely receive Rh negative blood of a compatible ABO type.) This means that people with O negative blood are considered universal donors; their blood type always is in demand at blood centers.

Blood can be typed by several other minor antigens, such as Kell, Duffy, and Lewis. These minor antigens can become important when a patient has received many transfusions. These patients tend to build up an immune response to the minor blood groups that do not match their own. Upon receiving a transfusion with a mismatched minor blood group, they may have an adverse reaction. A third group of antigens to which a patient can react are residues from the donor's plasma that have attached to the RBCs. To eliminate this problem, the RBCs are rinsed to remove plasma residues. These rinsed cells are called washed RBCs.

Blood components used in transfusion

Most blood collected from donors is broken down (fractionated) into components that are used to treat specific problems or diseases. Treating patients with blood components is the most efficient way to use the blood supply.

RED BLOOD CELLS. Red blood cells (RBCs) carry oxygen throughout the body. They obtain oxygen as they pass through the lungs and give up oxygen to the other tissues of the body as they are pumped through arteries and veins. When patients do not have enough RBCs to properly oxygenate their bodies, they can be given a transfusion with RBCs obtained from donors. RBCs are recovered from whole blood after donation. They are then typed, removed from the watery blood plasma to minimize the volume (packed), and stored. They are given to people who have anemia (including thalassemia), whose bone marrow does not make enough RBCs, or who have other conditions that decrease the number of RBCs in the blood. Occasionally, red blood cells from rare blood types are frozen. Once frozen, RBCs can survive for as long as 10 years. Packed RBCs are given in the same manner as whole blood.

PLASMA. Plasma is the liquid portion of blood. It contains many useful proteins, especially clotting factors and immunoglobulins. After they are processed, plasma or plasma factors (fractions) are usually frozen. Some plasma fractions are freeze-dried. These fractions include clotting factors I through XIII. Some people have an inherited disorder in which the body produces too little of the plasma clotting factors VIII (hemophilia A) or IX (hemophilia B). Transfusions of these clotting factors help people with hemophilia stop bleeding. Frozen plasma must be thawed before it is used and freeze-dried plasma must be mixed with liquid (reconstituted). In both cases, these blood fractions are usually small in volume and can be injected by syringe and needle.

PLATELETS. Platelets are small bodies in the blood that are essential for clotting. People who do not have enough platelets have bleeding problems. People who have lymphoma, leukemia, or thrombocytopenia, and people who are receiving cancer therapy do not make enough platelets. Platelets have a very short shelf life; they must be used within five days of blood donation. Platelets are packed into bags. A platelet transfusion is given in the same manner as whole blood.

IMMUNOGLOBULINS. Immunoglobulins are the infection-fighting fraction of blood plasma. They are also known as gamma globulin, antibodies, and immune serum. This blood fraction is given to people who have difficulty fighting infections, especially people whose immune systems are depressed by diseases, such as AIDS. Immunoglobulins are also used to prevent tetanus after cuts, to treat animal bites when rabies infection is suspected, or to treat severe childhood diseases. Generally, the volume used is small, and the immunoglobulins can be injected.

WHITE BLOOD CELLS. White blood cells (WBCs) are another infection-fighting component of the blood. On rare occasions, white blood cells are given by transfusion to treat life-threatening infections. Such transfusions are given when the WBC count is very low or when WBCs are not functioning normally. Most of the time, however, antibiotics are used in these cases.