AssessmentsBlood products and transfusion: Clinical practice
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 74-year-old Caucasian woman presents to her family doctor with a 1-day history of tarry, black stools. She is somewhat confused, but says she has passed multiple bowel movements with this appearance in the last 24 hours. Her past medical history is significant for atrial fibrillation, for which she takes warfarin. Her laboratory results demonstrate an INR of 10.1 and a hemoglobin value within the normal range. Her family doctor, suspecting an upper gastrointestinal bleed, sends the patient to hospital. In the hospital, she is administered vitamin K, coagulation factors, and fresh frozen plasma. Four hours later, the patient develops chest pain and dyspnea. Her chest X-ray is pictured below.
Which of the following is the most likely cause for her shortness of breath?
Content Reviewers:Rishi Desai, MD, MPH
Blood transfusions are life-saving treatment options, to the point where informed consent is not necessarily required if it has to be done in an emergency to save a person’s life.
Additionally, blood banks have developed a sophisticated variety of blood products to ensure that they’re free of infection and compatible with a recipient’s blood type.
To understand them all, let’s review the normal components of blood. When blood is spun down in a centrifuge, the layers separate out.
The first layer is the cellular component, which accounts for 45% of blood, and includes red blood cells, or RBCs, white blood cells, or WBCs, and platelets.
Second is the acellular component, also called plasma, which accounts for 55% of blood.
Plasma is composed of everything that isn’t a cell, including proteins like albumin, electrolytes like sodium, molecules like glucose, coagulation factors like factor 8, and lipoproteins like low-density lipoprotein, or LDL.
Now, the main blood products that can be transfused are packed red blood cells, or PRBCs, which are RBCs that had most of their surrounding plasma removed, fresh frozen plasma, or FFP, which is made of all the coagulation factors together, platelets, prothrombin complex concentrates, or PCCs, which are composed of factors 2,7,9 and 10, cryoprecipitate, which is made of fibrinogen, von willebrand factor, and factors 8 and 13 and finally pure coagulation factor concentrates, like pure factor 8.
Alright, so acutely bleeding or anemic patients can require PRBC transfusions.
To do that, a sample of their blood is taken, and the bank performs a “type and screen”.
Type refers to looking at the recipient’s RBCs surface antigens, which include their ABO, Rh or D-antigens and checking if they’re compatible with the donor’s RBCs.
Screen refers to looking for antibodies in the recipient’s plasma, and if they’re present, then making sure that the donor RBCs don’t have antigens that would get bound by those antibodies. This is done to prevent a transfusion reaction.
If the donor and recipient are compatible, the PRBC transfusion is given.
On average, one unit of PRBCs increases the hemoglobin concentration by 1 gram per deciliter, and generally, the goal is to keep the hemoglobin above 7 g/dl.
In emergencies, group O negative blood is considered a universal donor, and can be transfused to anyone.
That’s because group O negative blood has no antigens on the RBC surface, so there’s no risk of incompatibility.
Usually, platelets are transfused when the platelet count goes below 10,000 cells per millimeter square in an asymptomatic patient, or below 50,000 if the patient is actively bleeding or will have a procedure, like a lumbar puncture.
That’s because the underlying pathophysiology in these disorders is abnormal activation and consumption of platelets, so transfusing platelets only adds fuel to the fire.
Fresh frozen plasma, or FFP is a concentrate composed of all the coagulation factors.
Prothrombin complex concentrates or PCCs contain factors 2,7,9 and 10, and are much faster in onset compared to FFP.
Therefore, PCCs are used in life-threatening warfarin-induced bleeding, like an intracranial hemorrhage.
Cryoprecipitate is composed of fibrinogen, von willebrand factor, and factors 8 and 13.
Because specific concentrates are now widely available, cryoprecipitate is seldom used clinically, but can be used in DIC to replace the depleted fibrinogen, or in factor 13 deficiency.
Finally, there’s plasmapheresis; a procedure in which blood is removed from the body, filtered through a device, and separated into its individual components.
Some of the filtered blood components are removed, and the rest of the blood returns to the patient.
Plasma exchange is similar to plasmapheresis, except instead of simply removing some blood components, those components are “exchanged” for a non-diseased component from the bank.
Alright, now transfusions can cause a lot of potential complications, some of which are life-threatening. We can generally divide them into non-immune mediated and immune mediated complications.
Kicking off with the non-immune mediated complications. Blood transfusions risk transmitting infectious microorganisms The most common ones - in descending order are cytomegalovirus, or CMV, which can occur once every 100 transfusions, hepatitis B, which occurs about once every 200,000 transfusions, and hepatitis C and HIV, both of which occurs about once every 2 million transfusions.
These numbers vary quite a bit depending on the healthcare setting because the way blood is screened differs around the world.
Because CMV infects white blood cells, one common method of preventing it is by removing the white blood cells from the product, a process called leucodepletion.
Okay, now frequent PRBC transfusions can lead to an iron-overload state, which is called secondary hemochromatosis.
Also, platelets are typically stored in a warm environment, which also provides a nice temperature for bacteria to grow.
Additionally, to prevent the blood from clotting, an anticoagulant is added to the transfusion product.