CLS 306 - Blood/Blood Components

Blood / Blood Components

Blood Cellular Elements

• Blood consists of:
  • Plasma
  • Platelets
  • Red blood cells
  • White blood cells

Blood Cellular Elements & Location of Formation

• Blood cells are formed in the bone marrow from stem cells.
• Red blood cells (erythrocytes)
• White blood cells (leukocytes):
  • Lymphocyte
  • Monocyte
  • Eosinophil
  • Basophil
  • Neutrophil
• Platelets (thrombocytes)

Blood / Blood Components

• Whole Blood (WB)
  • Leuko-reduced (LR)
  • Non-LR
• Red Blood Cells (RBCs); aka, Packed Cells
  • RBCs (non-LR)
  • LR-RBCs
  • Washed (W-RBCs)
  • Frozen / Deglycerolized (F-RBCs / Deglyc-RBCs)
• Platelets (Plt)
  • Non-LR
  • LR
  • Types of Products
    • Platelet Concentrates (Plt Conc) - made from a whole blood donation; commonly call "Random"
    • Plateletpheresis (Pltph) - collected by an apheresis machine
    • Cold-stored Platelets
• Plasma
  • Fresh Frozen Plasma (FFP)
  • Plasma Frozen within 24 hrs from collection (PF24)
  • Freeze-Dried Plasma (FDP)
  • Cryoprecipitate (Cryo)

RBC Storage: Anticoagulant Preservative Solutions

• Used in blood collection bags:
  • CPD (Citrate Phosphate Dextrose)
  • CP2D (Citrate Phosphate Double Dextrose)
  • ACD (Acid Citrate Dextrose)
  • CPDA-1 (Citrate Phosphate Dextrose Adenine)
  • Additive Solutions
    • AS-1 (Adsol)
    • AS-3 (Nutricel)
    • AS-5 (Optisol)
• CPD, CP2D, ACD have a 21-day expiration
• CPDA-1 has a 35-day expiration
• Additive Solutions have a 42-day expiration

RBC Storage Lesion: Biochemical & Morphological Changes

• Biochemical Changes
  • ↓ Glucose
  • ↓ ATP ≈ ↑ Hgb O_2 affinity
  • ↓ 2,3 DPG ≈ ↑ Hgb O_2 affinity
  • ↓ pH
  • ↑ K+ in supernatant & free Hgb.
• Morphological Changes
  • Irreversible shape deformity
  • ↑ Osmotic Fragility

Platelet Storage Lesion: Morphological Changes

• Biochemical Changes
  • ↓ Glucose
  • ↓ pH
  • ↑ lactate dehydrogenase (LDH)
• Morphological Changes
  • Very fragile / fragmentation; degranulation occurs
  • Without continuous rotation, platelets will clump together
  • Irreversible shape deformity from discoid to spherical
  • Decreased in in-vivo recovery, survival, & function

Plasma Storage Lesion: Biochemical Changes

• Morphological Changes
  • There are no cellular elements found in plasma products, therefore, there are no morphological changes occurring.
• Biochemical Changes
  • Deterioration of heat-labile coagulation factors, i.e., Factor V & VIII

Element Life Spans in Body

• RBC: ≈ 120 days
• Platelets: ≈ 10 days
• WBCs: ≈ 1-3 days
• Coag Factors (half-life): ≈ hours

Pharmaceutical Blood Derivatives

• Plasma coagulation factors can be further manufactured into separate pharmaceutical products.
• These blood derivatives can be lyophilized or liquid.
• Must have a prescription to use

Components Made From Whole Blood Donation

• Whole Blood
  • Red Blood Cells
    • To increase the amount of red blood cells after trauma or surgery or to treat severe anemia.
    • 42 days in the refrigerator or 10 years in the freezer
  • Fresh Frozen Plasma
    • To correct a deficiency in coagulation factors or to treat shock due to plasma loss from burns or massive bleeding.
    • 1 year in the freezer
  • Concentrate of Platelets
    • To treat or prevent bleeding due to low platelet levels. To correct functional platelet problems
    • 5 days at room temperature
  • Cryoprecipitate
    • To treat fibrinogen deficiencies
    • 1 year in the freezer

Whole Blood (WB) Products

WB - Indications

• Acute Hemorrhaging - Trauma or massive bleed
• Volume Replacement - hypovolemia
• Increase oxygen-carrying capacity to vital organs, e.g., brain, heart, liver, kidneys, etc.

WB - Characteristics

• Volume: 400 - 500 ml
• Storage Temp: 1 - 6°C
• Expiration: CPD or CP2D - 21 days; CPDA1 - 35 days
• Transport Temp: 1 - 10°C
• Contents: RBCs, Plasma, WBCs, & Plts
• Quality Control Requirements: None

Low-Titered "O" Whole Blood (LTOWB)

LTOWB - Indications

• The Joint Trauma System, the Defense Committee on Trauma, & the Armed Services Blood Program have endorsed (2021) the use of LTOWB as the resuscitation product of choice for the treatment of hemorrhagic shock for all casualties.
• THOR (Trauma Hemostasis & Oxygenation Research) published data (2021) that shows, of the 103 U.S. Level 1 Trauma facilities, approx. 57 are using LTOWB and 95 are using Grp A plasma
• Acute Hemorrhaging - Trauma or massive bleed
• Volume Replacement - hypovolemia
• Increase oxygen-carrying capacity to vital organs, e.g., brain, heart, liver, kidneys, etc.

LTOWB - Characteristics

• Volume: 400 - 500 ml
• Storage Temp: 1 - 6°C
• Expiration: CPD or CP2D - 21 days; CPDA1 - 35 days
• Transport Temp: 1 - 10°C
• Contents: RBCs, Plasma, WBCs, & Plts
• Quality Control Requirements:
  • A & B hemagglutinin titer is < 1:256; can be lower for more conservative titer
  • Must be labeled as "Low Titer"

Leuko-Reduced (LR) Whole Blood

• Volume: 400 - 500 ml
• Storage Temp: 1 - 6°C
• Expiration: CPD or CP2D - 21 days; CPDA1 - 35 days
• Transport Temp: 1 - 10°C
• Contents: RBCs, Plasma, WBCs, & Plts
• Quality Control Requirements:
  • < 5x106 WBCs & ≥ 85% RBC Recovery in at least 95% of the units tested

Red Blood Cells (RBCs) Products

RBC COMPONENTS

• There can be 3 types of RBC components:
  • RBC - 21- or 35-day expiration
  • RBC with an additive solution - 42-day expiration
  • Leuko-reduced RBC (WBCs removed and additive solution is added) - 42-day expiration

RBCs - Indications

• Anemic conditions to increase the oxygen-carrying capacity to vital organs
• Less volume; helps prevent hypervolemia
• 98% of blood transfusions is using this product
• Leuko-reduced RBCs are majority of the blood made / available

RBCs - Characteristics

• Volume: ≈ 250 ml (no additive sol't used)
• Storage Temp: 1 - 6°C
• Expiration: Same as WB
• Transport Temp: 1 - 10°C
• Contents: RBCs, plasma, residual WBCs & Plts; 1 unit of RBCs raises Hgb ~ 1 gm/dL or Hct ~ 3%
• QC Requirements:
  • RBC Hct ≤ 80% for non-additive RBC product

Additive-RBCs - Characteristics

• Volume: ≈ 300 ml
• Storage Temp: 1 - 6°C
• Expiration: 42 days
• Transport Temp: 1 - 10°C
• Contents: RBCs, plasma, residual WBCs, additive solution, & Plts
• QC Requirements:
  • No Hct QC on additive RBC product as final product Hct after adding the additive solution is 55 - 65%

LR-RBCs

LR-RBCs - Indications

• Same as RBCs, but has other advantages:
  • Helps reduce Febrile Transfusion Reactions and Transfusion-related Acute Lung Injury (TRALI) Transfusion Reactions due to the lack / reduced number of WBCs & plts in the product
  • Helps reduce the recipient's immune response to develop Abs against WBCs & plts

LR-RBCs - Characteristics

• Volume: 300 ml
• Storage Temp: 1 - 6°C
• Expiration: 42 days
• Transport Temp: 1 - 10°C
• Contents: RBCs & additive Sol't; essentially no WBCs or Plts
• Quality Control Requirements:
  • < 5x106 WBCs & ≥ 85% RBC Recovery in at least 95% of the units tested

LR Process

• During the processing steps, the WB or RBC product is filtered using a leukocyte removal filter.
• The unit is hung upside down to "drain" blood through the leukocyte removal filter which is connected to another bag to capture the filtered blood. This filtration process takes a few hours for completion.
• The resulting "filtered" blood product is now named, "leuko-reduced"

Washed-RBCs

W-RBCs - Indications

• Same as RBCs & LR-RBCs, but other advantages:
  • Removes plasma proteins (e.g., IgA, IgG, etc) during washing cycles
  • Removes other accumulated substances present in stored blood, e.g., K+

W-RBCs - Characteristics

• Volume: 180 - 200 ml
• Storage Temp: 1 - 6°C
• Expiration: 24 hrs (open system* process)
• Transport Temp: 1 - 10°C
• Contents: RBCs, Saline
• Quality Control Requirements:
  • Product Hct 70-80%
• An "open system" means the hermetic seal on the original blood bag is broken to gain access into the product. Once the hermetic seal is broken, the expiration date changes from the original outdate to 24 hrs.

Frozen RBCs (F-RBCs)

F-RBCs - Indications

• Same as W-RBCs, but with other advantages:
  • Rare phenotypes are frozen for future transfusions, e.g., hr" neg, Oh , U neg, etc.
  • Autologous blood

F-RBCs - Characteristics

• Volume: 250 - 300 ml
• Cryoprotective Agents Used:
  • High Glycerol (40%) - most commonly used in the USA
  • Low Glycerol (15-20%)
• Limitation: must be frozen within 6 days from collection
• Storage Temp:
  • High Glycerol: ≤ − 65°C in a mechanical BB ultra-low freezer (usually @ − 80°C)
  • Low Glycerol: ≤ − 165°C in liquid nitrogen vapor or ≤ − 196°C in liquid nitrogen in a monitored liquid nitrogen tank
• Expiration: 10 yrs;
• Transport Temp:
  • High Glyc - Dry Ice
  • Low Glyc - Liquid N2
• Contents: RBCs & Cryoprotective Agent
• Quality Control Requirements: None

Transfusion of F-RBCs

• Prior to transfusion, removal of all the cryoprotective agent is performed using varying dilutions of saline with dextrose. This removal process is called deglycerolization.
• In USA, must, first, rapidly thaw the F-RBCs in a 37°C waterbath before removing the cryoprotective agent.
• The thawed & processed F-RBCs product is now called a "deglycerolized RBCs" product.

Deglycerolized Red Blood Cells (Deglyc RBCs)

Deglyc RBCs - Characteristics

• Volume: 250 ml
• Storage Temp: 1 - 6°C
• Expiration: 24 hrs (open system process)
• Transport Temp: 1 - 10°C
• Contents: RBCs & 0.9% Saline w 0.2% dextrose
• Quality Control Requirements:
  • ≥ 80% RBC Recovery
  • < 1% Residual Glycerol

New Future Product - Lyophilized RBCs

• New research to investigate the survival of RBCs after freeze-drying process and rehydration.
• Need to quantify the RBC survival and the level of oxygen carrying capacity.
• Some issues with RBC lyophilization, thus far:
  • Lyophilizing process affect on RBCs
  • Drying damage affects
  • Rehydration issues
• Platelets (Plts) Products

What Do Platelets Do?

• Clot Formation

Platelet Product - Indications

• Replace platelets when platelet count is low
• Petechiae / ecchymosis may be present
• Also replace platelets when Platelet Function Test and / or the Clot Retraction Test are / is abnormal (suggests a platelet function disorder)
• Prevent bleeding / oozing
• Stop hemorrhage

Platelet Products - Pathogen Reduction Technology (PRT)

• New treatment to platelet products that is effective in preventing nucleic acid replication for bacterial, viral, and parasitic pathogens.
• Treatment mitigates risk for emerging & unknown pathogens.
• FDA-approved treatment is with amotosalen (psoralen) plus UVA light phototherapy.
• Still under development is PRT for WB & RBCs using riboflavin plus UVA light.

Platelet Concentrates (Plt Conc)

Plt Conc - Indications

• Platelet Concentrate product - raises Plt Ct to ≈ 5,000/μL in a 70-kg adult
• Corrected Count Increment (CCI) is:
  • Used to measure platelet refractoriness
    • Immune
      • Plt Ab
      • HLA Ab
      • Passive Immunity
    • Non-immune
      • Sepsis
      • Splenomegaly
      • Aplasia
      • Cirrhosis
      • Drugs / Antibiotics
      • Bleeding
      • DIC
  • Corrected Count Increment (CCI) is (cont.):
    • Based on the number of platelets transfused and the Body Surface Area (BSA) of the patient
    • Performed 10 - 60 mins post plt transfusion
    • Normal - > 7,500 µL & above 4,500 µL at 24 hrs
    • Abnormal - < 5,000 µL
  • Platelet transfusion response dependent on a number of factors, e.g., bleeding, spleen sequestration, alloimmunization / plt Ab, disease state, etc.

Plt Conc - Characteristics

• Made from a whole blood collection by low RPM differential centrifugation
• Volume: 50 - 70 ml
• Storage Temp: 20 - 24°C with constant agitation
• Expiration: 5 days; Pooled: 4 hrs
• Transport Temp: 20 - 24°C
• Contents: Plts, WBCs, residual RBCs, Plasma
• Quality Control Requirements:
  • ≥ 5.5 x 1010 Plts
  • pH ≥ 6.2
  • No visible aggregates

LR Platelet Conc

• Volume: 50 - 70 ml
• Storage Temp: 20 - 24°C with constant agitation
• Expiration: 5 days; Pooled: 4 hrs
• Transport Temp: 20 - 24°C
• Contents: Plts, residual RBCs, Plasma
• Quality Control Requirements:
  • ≥ 5.5 x 1010 Plts
  • pH ≥ 6.2
  • No visible aggregates
  • < 8.3x105 WBCs in 95% of the units tested

Plasma Products

Fresh Frozen Plasma (FFP)

FFP - Indications

• Replacement of all coagulation factors NOTE: Heat-labile factors are V & VIII with half-life of 12 & 10 hrs, respectively.
• Massive hemorrhage - hypovolemia NOTE: Grp A plasma can be used on ANY Trauma patient, regardless of patient's blood type.
• Re-establishes normal coagulation scheme in massive hemorrhage

FFP - Characteristics

• Volume: 200 - 250 ml
• Storage Temp: ≤ − 18°C
• Expiration: Frozen - 1 yr
• Thaw for transfusion: thaw FFP in 37°C water bath; expiration & storage - 24 hrs at 1-6 °C
• Transport Temp: Frozen - ≤ − 18°C; Liquid thawed FFP - 1- 6°C
• Contents: Plasma, no cellular elements
• Quality Control Requirements: None

Plasma Frozen Within 24 Hrs From Collection (PF24) - Indications

• Product is NOT frozen within the same time limit as FFP, but within 24 hrs from collection.
• Used only as liquid plasma because the heat-labile coag factors are essentially gone, but the more stable coag factors are still present, e.g., Factors II, VII, IX, X, & XI.

PF24 - Characteristics

• Volume: 200 - 250 ml
• Storage Temp: ≤ − 18°C
• Thaw for transfusion: thaw PF24 in 37°C water bath; expiration & storage - 24 hrs at 1-6 °C
• Transport Temp: Frozen - ≤ − 18°C; Liquid thawed PF24 - 1-6°C
• Contents: Plasma, no cellular elements
• Quality Control Requirements: None

Freeze-Dried Plasma (FDP)

• FDA recently approved the use of freeze-dried plasma that can be used on American military personnel out in the battlefield – this type of plasma has not yet been approved for use in the civilian sector (Jul 2018)
• In Oct 2018, the FDA published guidance for manufacturers to make freeze-dried plasma (FDP).
• Use of pre-hospital plasma transfusion (Trauma) of FDP statistically significant where there was a 27.5% reduction in 30-day mortality.
• Minor reductions in procoagulant or anticoagulant plasma protein activities or clotting times; however, no significant differences in clotting factor content.
• Currently, the French & Germans have a glass bottle packaging of FDP…which is considered suboptimal
• In the US, FDP is projected to be in sterile plastic bags with ports and tubing allowing rapid reconstitution with sterile water for infusion.

FDP - Characteristics

• Volume: 260 - 270 ml or 700 ml (apheresis)

• Storage Temp: Room Temperature

• Expiration: 2 yrs

• Transport Temp: Room Temperature

• Contents: Plasma, no cellular elements

• Quality Control Requirements: ???
  Advantages of FDP:

• Storage Temperature - Room

• Reconstitution (quick process)

• Maintaining inventory of AB plasma in rural hospitals

• Use in the field (Trauma) to increase survivability / decrease mortality

Cryoprecipitate (Cryo)

CRYO - Indications

• Replacement of Factor VIII or Fibrinogen or vWF, but primarily used to replace Fibrinogen
• Each unit raises the fibrinogen level 5-10 mg/dL
• Can be used to make biologic fibrin glue in certain surgeries to stop ooze bleeding

CRYO - CHARACTERISTICS

• Made from FFP
• Volume: 15 - 25 ml
• Storage Temp: Frozen - ≤ −18°C; for transfusing
• Expiration: Frozen - 1 yr;
• Thaw for transfusion: thaw cryo in 37°C water bath; store at 20 - 24°C &
  • Expiration
    • 6 hrs (individual unit)
    • Pooled - 4 hrs in "open" system OR 6 hrs in "closed" system
• Transport Temp: Same as Storage Temp
• Contents: 700 mg Fibrinogen, 200 IU Factor VIII, von Willebrand's Factor (vWF); some Plasma
• Quality Control Requirements: ≥ 80 IU Fac VIII; 150 mg Fibrinogen

Fibrinogen Complex - Indications

• Treatment & control of bleeding, i.e., massive hemorrhage, fibrinogen deficiency, etc.
• Replacement of Fibrinogen or vWF or Fac XIII
• Can not use this for the replacement for Fac VIII

Fibrinogen Complex - Characteristics

• Pooled Cryos (up to 4 ABO identical) using pathogen-reduction filtration system
• Volume: 60 - 100 ml
• Storage Temp: Frozen - ≤ −18°C
• Expiration: Frozen - 1 yr;
• Thaw for transfusion: thaw cryo in 37°C water bath
• Post-thaw storage & expiration - store at 20 - 24°C for 5 days
• Transport Temp: Same as Storage Temp or 20 - 24°C
• Contents: ≈ 3000 mg Fibrinogen, von Willebrand's Factor (vWF); some Plasma
• Quality Control Requirements: 150 mg Fibrinogen

Blood Components Collected by Automated Method

Apheresis Products

• The apheresis machine has the capability to select certain blood elements to be collected and return the remaining blood to the donor.
  • When cellular elements are collected, the official term used is "cytapheresis", i.e., erythrocytapheresis (RBC apheresis), plateletpheresis, & granulocyte pheresis
    • RBC products are most commonly collected.
    • Plateletpheresis.
  • When only the plasma element is collected, the official term is "plasmapheresis."
• The donation / product collection time is usually "hours" versus the 10-minute manual WB donation. Therefore, apheresis donors are "graduates" from the manual whole blood donation program.
• Apheresis products:
  • Are larger in volume
  • Have increased quantities of cellular elements
  • Uses less manipulation in processing the product when compared to the WB-derived components
  • Can collect both non leuko-reduced products and leuko-reduced (LR) products without the added filtration processing step

Plateletpheresis (Pltph)

PLTPH - Indications

• Pltph product
  • Is equivalent to ≈ 4-6 Plt concs
  • Raises patient post-transfusion Plt Ct to ≈ 40,000/μL in a 70-kg adult
• Corrected Count Increment (CCI) is also used to determine platelet refractoriness.
• Platelet transfusion response dependent on a number of factors, e.g., bleeding, spleen sequestration, alloimmunization / plt Ab, disease state, etc.

PLTPH - Characteristics

• Volume: 200 - 300 ml
• Storage Temp: 20 - 24°C with constant agitation
• Expiration: 5 days OR 7 days (using PRT)
• Transport Temp: 20 - 24°C
• Contents: Plts, WBCs, no RBCs, Plasma
• Quality Control Requirements:
  • ≥ 3.0 x 1011 Plts
  • pH ≥ 6.2
  • No visible aggregates

LR PLTPH - Characteristics

• Volume: 200 - 300 ml

• Storage Temp: 20 - 24°C with constant agitation

• Expiration: 5 days OR 7 days (using PRT)

• Transport Temp: 20 - 24°C

• Contents: Plts, Plasma, no RBCs or WBCs

• Quality Control Requirements:

  • ≥ 3.0 x 1011 Plts
  • pH ≥ 6.2
  • No visible aggregates
  • < 5x106 residual WBC in 95% of the units tested
    Platelet Product

• Some US trauma services / helicopter services carry cold platelets in an ice chest when picking up trauma victims is rural areas.

• It has been clinically shown that cold-storage platelets will stop bleeding quicker than room temperature platelets

• FDA will approve the use of cold storage platelet products, if the manufacturer applies for a variance to the existing law of room temperature storage.