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1. Introduction A place where blood is collected from donors, typed, separated into components, stored, and prepared for transfusion to recipients

2. Blood group system There are 30 blood groups systems are identified by ISBT Based on the red cell antigen ABO Rh Kell Lewis Duffy Kidd Colten……

3. Important ? ABO Rh Most immunogenic

4. No H antigen strong anti H ,anti A, anti B antibodies

5. Parameter ABO Rh type Location Chr 9 Chr 1 Antigens A,B,AB D Distribution RBC, Platelets, Body fluids RBC alone Antigen development Week express at birth Fully developed at birth Nature of antibodies Naturally occurring Immune Antibody class IgM IgG Compliment activation Yes No Optimal reaction medium Saline Antihuman globulin

6. Blood donation Types Voluntary Professional or paid Replacement

7. Donor selection process 4 parts Predonation counselling Medical history Physical examination HB estimation

8. Types of blood bags

9. Anticoagulant

10. Components & separation

11. Screening Malaria Syphilis HIV 1 & 2 Hepatitis B Hepatitis c

12. CROSS-MATCHING It is a test performed before a blood transfusion as part of blood compatibility testing. Normally, this involves adding the recipient's blood plasma to a sample of the donor's red blood cells.

13. Anti-human Globulin Reagent

14. PLASMAPHARESIS From the greek Plasma,something molded aphairesis , taking away Is the removal and treatment of blood from the body and return of components of blood( i.e blood cells)to the body after extraction of plasma. OR Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases. It is also known as therapeutic plasma exchange.

15. Purpose In an autoimmune disease, the immune system attacks the body's own tissues. In many autoimmune diseases, the chief weapons of attack are antibodies, proteins that circulate in the bloodstream until they meet and bind with the target tissue. Once bound, they impair the functions of the target.

16. Plasmapheresis is used to remove antibodies from the bloodstream, thereby preventing them from attacking their targets. It does not directly affect the immune system's ability to make more antibodies, and therefore may only offer temporary benefit.

17. Indications MAJOr Guillain-Barré syndrome Myasthenia gravis Chronic inflammatory demyelinating polyneuropathy Thrombotic thrombocytopenic purpura /TTP Idiopathic thrombocytopenic purpura /ITP Dermatomyositis Good pasteur’s syndrome Multiple sclerosis

18. MINOR Hyperviscosity syndromes: Cryoglobulinemia Paraproteinemia Wegener's granulomatosis Lambert-Eaton Syndrome Antiphospholipid Antibody Syndrome (APS or APLS) Microscopic polyangiitis After transplantation of kidney

19. Behcet syndrome HIV-related neuropathy [8] Graves' disease in infants and neonates Pemphigus vulgaris Multiple sclerosis Rhabdomyolysis Toxic Epidermal Necrolysis (TEN) HELLP syndrome PANDAS syndrome Refsum disease

20. Cell separator The machine used for Plsmapheresis is called cell separator. 40,00,000 (40 lakh) Each time new set of tubing and disposable kit is used.

21. procedure Preparation Good nutrition and plenty of rest make the procedure less stressful. Some of patient's medications should be discontinued before the plasmapheresis session. SETPS Plasmapheresis requires insertion of a venous catheter, either in a limb or central vein. Central veins allow higher flow rates and are more convenient for repeat procedures, but are more often the site of complications, especially bacterial infection.

22. Blood is initially taken out of the body through a needle or previously implanted catheter. The catheter is two way,one is used to withdraw blood from the body and other is used to introduce plasma substitute in patient,s body. Anticoagulant is also given during the procedure. First blood passes through the air filter,if air is present in blood it is filtered here. Then blood enters into ball(centrifuge). Plasma is then removed from the blood by a cell separator. When the blood is entering in the ball,at the same time some air of ball is collected in air bag.

23. After sometime,when ball becomes full of cells the machine takes a break and blood cells are returned back to the body,and air is returned back from the airbag to the the ball. Now 1 cycle is completed. Same process is repeated again and again and mostly 8 to 10 cycles are required. Extracted plsma is discarded. In females less no.of cycles are required. The whole procedure is repeated 5 times but on alternate days.

24. Three procedures are available: "Discontinuous flow centrifugation." Only one venous catheter line is required. Approximately 300 ml of blood is removed at a time and centrifuged to separate plasma from blood cells. "Continuous flow centrifugation." Two venous lines are used. This method requires slightly less blood volume to be out of the body at any one time. "Plasma filtration." Two venous lines are used. The pasma is filtered using standard hemodialysis equipment. It requires less than 100 ml of blood to be outside the body at one time.

25. Aftercare The patient may experience dizziness,nausea , numbness, tingling, or lightheadedness during or after the procedure. These effects usually pass quickly, allowing the patient to return to normal activities the same day .

26. complications Hypotention Anaphylaxsis or allergic reactions Bacterial infections Supression of immune system Bleeding or hematoma due to anticoagulant

27. BLOOD TRANSFUSION REACTIONS 41

28. DEFINITION Any unfavorable and harmful transfusion related events occurring in the patient during or after transfusion of blood or components is called transfusion reaction.” 42

29. COMMON CAUSES OF TR Misidentification of the patient. Improper sample identification. Wrong blood issued. Administration error. Technical error. Storage error. 43

30. TYPES OF TRANSFUSION REACTIONS 44

31. CLASSIFICATION 45

32. Haemolytic TR ( HTR) Haemolytic TR are most severe type of transfusion reactions and can be categorized into two types. A. Immediate HTR / Intravascular HTR B.Delayed HTR / Extra vascular HTR 46

33. IHTR or Intravascular HTR In intravascular transfusion reaction the haemolysis of red cells takes place within the circulatory system. Haemolysis occur within few min after starting transfusion ( <24 hrs ). 47

34. This type of reaction is mainly due to IgM ab’s (ant-A, & anti-B), mediated by the rapid activation of complement and is usually associated with the transfusion of ABO in compatible blood 48

35. SIGNS AND SYMPTOMS Fever Chills Hypotension Chest and back pain Nausea Dyspnea Vomiting Haemoglobinuria Acute renal failure Pain at transfusion site Shock & DIC 49

36. MANAGEMENT AND THERAPY Stop transfusion immediately. Mannitol is the agent used to prevent the renal failure. Hypotension: intravenous fluid and vasoactive drugs .e.g. dopamine 50

37. Delayed HTR / Extra vascular HTR Extravascular TR are rarely severe and mainly due to IgG antibodies, e.g. Rh , kell or Duffy system. These ab’s bring about the destruction of red cells by the macrophages in the spleen or liver. Haemolysis occur after few hours or after about 3-7 days of transfusion. 51

38. 52

39. Conti.. 53

40. IgG antibodies coated red cells interact with receptors of phagocytic cell (macrophage). Phagocytic cell engulfs the antibody coated cell and incorporates it into the intracellular vacuole. Lysis of red cells with in the intra cellular vacuole of phagocytic cell. 54

41. Extra vascular HTR cont.. Delayed HTR which could be due to.. Primary allo -immunization Anamnestic or secondary response 55

42. ANAMNESTIC RESPONSE TO TRANSFUSED RBC Occurs in patients who has previously been sensitized by transfusion or pregnancy. The level of incomplete Ab is very low. Cannot be detected by standard pretransfusion procedure. There will be increased Ab production resulting in red cell destruction. 56

43. SIGNS & SYMPTOMS Fall in Hb Rise in bilirubin and mild jaundice with in 5-7 days of transfusion. Renal failure ( rare ) 57

44. NON HAEMOLYTIC TRANSFUSION REACTIONS Non haemolytic TR can be classified as Febrile non haemolytic TR (FNHTR) Urticarial (allergic) transfusion reaction Anaphylactic transfusion reaction Non cardiogenic pulmonary edema ( TRALI) Circulatory overload Graft versus host disease (GVHD) 58

45. FNHTR These reactions are the most common and account for over 90 % of TR. These are benign, self limiting reaction due to the presence of ab’s to WBC or PLT antigens and are usually seen in multi transfused patients. These are occur within minutes of starting the transfusion 59

46. PATHOPHYSIOLOGY 60

47. SIGNS AND SYMPTIMS Fever Chills Malaise 61

48. THERAPY AND PREVENTION Give leukocyte poor red cells. Anti pyretic can be given before starting transfusion, but they must be avoided as much as possible as they mask IHTR. 62

49. Laboratory investigations No evidence of haemolysis in post transfusion sample i.e. No red/pink plasma DCT negative No increase in bilirubin No haemoglobinuria 63

50. URTICARIAL(ALLERGIC) TR A type of immediate hyper sensitivity reaction. Allergic signs and symptoms appear within few minutes of exposure. 64

51. Causes of urticarial TR The donors plasma contain allergens which react with reagin present in patients plasma. The donors plasma contains reagin that combines with allergens in the patient plasma. 65

52. 66

53. SIGNS AND SYMPTOMS Local erythema Pruritis Hives(raised red wheal) Hypotension Loss of consciousness Shock 67

54. THERAPY AND PREVENTION Anti histamine 68

55. Anaphylactic TR This is a severe, life threatening reaction, which occur in rare patients who are IgA deficient and have developed anti- IgA ab’s . These reaction developed quickly- within minutes of starting the transfusion 69

56. SIGNS & SYMPTOMS Respiratory tract- cough, bronchospasm , dyspnea GIT- nausea, vomiting, diarrhoea Circulatory system- hypotension, syncope Skin- generalized flushing, Urticaria 70

57. THERAPY & MANAGEMENT Keep IV line open with normal saline. Inject epinephrine Inject antihistaminic Hypoxia- give oxygen by mask 71

58. TRANSFUSION RELATED ACUTE LUNG INJURY(TRALI ) Also known as non cardiac pulmonary edema Altered permeability of the pulmonary capillary bed by activation of complement , histamine mediated events, or prostaglandins which leads to fluid accumulation, inadequate oxygenation, and reduced cardiac return. 72

59. SIGNS & SYMPTOMS Acute onset of respiratory distress Dyspnea Cyanosis Fever Chill 73

60. THERAPY & MANAGEMENT Oxygen therapy Intubation Intravenous steroids Leukocyte poor component is used 74

61. POST TRANSFUSION PURPURA Occur with platelet concentrate transfusion. Rapid onset of thrombocytopenia due to production of platelet allo antibodies. Usually in multiparous female. Duration: 7-14 days from transfusion. Therapy: corticosteroids 75

62. GRAFT VERSUS HOST DISEASE Complication of blood component therapy or bone marrow transplantation. Patients at risk : Lymphopenic patients Bone marrow suppressed cases Fetus receiving intrauterine transfusion New born infants receiving exchange transfusion Congenital immunodeficiency syndrome 76

63. SIGNS & SYMPTOMS Fever Rash Diarrhea Hepatitis Liver dysfunction Bone marrow suppression Fatal THERAPY : corticosteroids , prevention. 77

64. NON IMMUNE NON HEMOLYTIC TRANSFUSION REACTION IMMEDIATE: bacterial overload circulatory overload DELAYED : iron overload 78

65. BACTERIAL OVERLOAD Bacterial contamination Due to toxins Antibiotics can be used for therapy. 79

66. CIRCULATORY OVERLOAD More volume of blood transfused Cause : fast rate Leads to congenital heart failure , pulmonary edema Signs: chest pain, cough, hypertension 80

67. IRON OVERLOAD Long term complication of RBC transfusion Also known as transfusion haemosiderosis. Iron accumulation : affect functions of heart, liver, endocrine system Signs: muscle weakness, fatigue, weight loss, mild jaundice, anaemia . Therapy: iron chelating agent. 81