Choosing Appropriate Blood Components and

DerivativesFor each case, decide which blood component or derivative would be most appropriate to transfuse.

Then select the best product from the available inventory.

CLS 423 Clinical Immunohematology II

Case One

• Sam is being treated for Hodgkin’s Lymphoma.• Below are the results from this morning’s CBC:– WBC 4.0 K/µL– RBC 2.64 M/µL– Hgb 6.8 g/dL– Hct 21%– Plt – 133 K/µL

Based on the CBC results, which of the following components would be appropriate to transfuse to Sam?

• Click on the box in front of your choice:– Granulocytes– FFP– Packed RBCs– Platelet Concentrates

Granulocytes

• Not indicated in Sam’s case.– Patient is not neutropenic– History does not indicate that the patient has an

infection.

• Please choose another component:– FFP– Packed RBCs– Platelet Concentrates

FFP

• There have been no coagulation tests ordered; there is no indication for plasma transfusion in this case.

• Please choose another component:– Granulocytes– Packed RBCs– Platelet Concentrates

Platelet Concentrates

• Sam’s platelet count is adequate.– Transfusion is usually not indicated unless the

platelet count is <10 K/µL in a nonsurgical patient.

• Please choose another component:– Granulocytes– FFP– Packed RBCs

Packed RBCs

• Correct!• Sam has a low hemoglobin and would benefit

from a RBC transfusion.• Sam’s Type and Screen results are:– A Rh Positive– Antibody screen: Negative using the gel method

Which of these packed RBC units would be compatible with Sam?

• O Rh Positive• A Rh Negative• AB Rh Negative• B Rh Positive• Either O Rh Positive or A Rh Negative packed

RBCs are group compatible with Sam’s A Rh Positive RBCs.

Which of the following attributes should be considered for Sam’s RBCs?• Irradiation• Leukoreduction• Washed• Patient’s with Hodgkin’s Disease have a high risk

of Transfusion Associated - Graft vs. Host Disease and should get irradiated cellular products.

• There is a strong chance that Sam will receive multiple transfusions, so leukoreduced units may be beneficial in preventing the formation of HLA antibodies and the complications associated with those antibodies.

Case Two• Jill is having cardiac bypass graft surgery this

afternoon.• These are her morning CBC results:– WBC 6.2 K/µL– RBC 3.85 K/µL– Hgb 12.6 g/dL– Hct 37%– Plt 40 K/µL

• These are her Type and Screen results:– O Rh Negative– Antibody screen negative with tube (PEG) method

Which of these components should be transfused

in order to prepare Jill for surgery?• Cryoprecipitate• FFP• Packed RBCs• Platelet Concentrates

Cryo and FFP

• There is no indication that any coagulation factors are low and in need of replacement.

• Please select a different component:– Packed RBCs– Platelet Concentrates

Packed RBCs

• Jill’s hemoglobin is acceptable. No RBC transfusion is necessary.

• Please select a different component:– Cryoprecipitate– FFP– Platelet Concentrates

Platelet Concentrates

• Jill’s platelet count is <50,000/µL. Platelet transfusion may be necessary to raise her count before proceeding with surgery.

Which of these platelet units would be appropriate to transfuse to Jill?

• A Rh Negative• AB Rh Negative• B Rh Negative• O Rh Positive• Any of these units could be transfused to Jill

as there are no antigens on her Group O RBCs that could interact with the antibodies in the donor units’ plasma.

O Rh Positive Platelets

• This unit could be transfused to Jill

HOWEVER since she is Rh Negative…

• She may need an RhIG injection afterward to prevent the formation of anti-D.

Case Three

• Steve was involved in a motor vehicle accident.

• He received 12 units of O Rh Negative uncrossmatched packed RBCs in the emergency room.

• He is being prepped for a splenectomy.

Steve’s lab results

• WBC 12 K/µL • RBC 3.80 M/µL• Hgb 10.6 g/dL• Hct 30.2 %• Plt 20 K/µL

• PT 24 sec• PTT 65 sec

Steve’s Type and Screen results

Anti-A Anti-B Anti-D A1 cells B cells Interpretation

0 3+mf 2+mf 4+ 0 ???

Screen IS 37 AHG CC Interpretation

I 0 0 0 3+ ???

II 0 0 0 3+

III 0 0 0 3+

How would you interpret Steve’s Type and Screen results?

• B Rh Positive, negative antibody screen• What explains the mixed-field reactions with

anti-B and anti-D?• The transfusion of a large number of O Rh

Negative packed RBCs units.• When a large quantity of RBCs is transfused in

less than 24 hours it is called ___________ .• Massive transfusion

Which of these components should Steve receive?

• Cryoprecipitate• FFP• Packed RBCs• Platelets

Packed RBCs

• At this time, Steve’s hemoglobin level is acceptable and transfusion of RBCs is not warranted as long as the patient is not actively bleeding. – Transfusion trigger is typically set at a hemoglobin of <7

g/dL• If the patient is currently bleeding, additional RBC

transfusions may be indicated.• Please select a different component:– Cryoprecipitate– FFP– Platelets

Cryoprecipitate

• Although the patient’s PT and PTT are elevated, cryoprecipitate only contains a limited number of coagulation factors and will not fully correct the multiple factor deficiencies.

• There is a better component choice available.• Please choose another component:– FFP– Packed RBCs– Platelets

FFP

• This will restore the multiple coagulation factors that were depleted as Steve bled.

• There is a second component that should be transfused at this time. Which one is it?– Cryoprecipitate– Packed RBCs– Platelets

Platelets

• Steve’s platelet count is low, especially for a pre-surgical patient, so a platelet transfusion is indicated.– Transfusion trigger <50,000/µL

Continue

Platelets

• Steve’s platelet count is low, especially for a pre-surgical patient, so a platelet transfusion is indicated.– Transfusion trigger <50,000/µL

• There is a second component that should be transfused at this time. Which one is it?– Cryoprecipitate– FFP– Packed RBCs

FFP

• This will restore the multiple coagulation factors that were depleted as Steve bled.

Which of these blood types would be suitable when selecting

FFP for Steve? • B Rh Negative• AB Rh Positive• O Rh Negative• A Rh Positive• The antibodies in the plasma of these donors

would not react with the antigens on Steve’s RBCs.

Case Four

• Jimmy is a 4 year old with Hemophilia A who is experiencing a bleed into his knee joints.

• Which of the following would provide the best treatment for Jimmie? Cryoprecipitate– FFP– Factor VIII concentrate– Platelet Concentrates

Platelet Concentrates

• While Jimmie does have a bleeding problem, platelets will not correct for the coagulation deficiency found in Hemophilia A.

• Please choose a different product:– Cryoprecipitate– FFP– Factor VIII Concentrate

FFP

• FFP is ideal when the patient has multiple factor deficiencies.

• In this case, we are missing 1 specific factor; there is a better choice.

• What is it?– Cryoprecipitate– Factor VIII Concentrate– Platelet Concentrates

Cryoprecipitate

• This is not a bad choice, but there is a better (safer) product.

• Please choose another product:– FFP– Factor VIII concentrate– Platelet Concentrates

Factor VIII Concentrate

• This derivative product would provide the safest and most effective treatment for Jimmie.– Processed to remove/destroy viruses– Known quantity of Factor VIII

Case Five

• Sue is scheduled for a liver transplant today.• She has a history of an anaphylactic

transfusion reaction.– The transfusion reaction workup revealed Sue has

no IgA in her serum, and has formed anti-IgA.

• The surgeon has ordered 10 units of packed RBCs and 10 units of Plasma to be prepared for the transplant surgery.

Which of these RBC components would prevent Sue from having another

anaphylactic transfusion reaction?• Frozen/Deglycerolized RBCs• Irradiated packed RBCs• Leukoreduced packed RBCs• Washed packed RBCs• Washed packed RBCs are most suitable for prevention

of anaphylactic transfusion reactions• Deglyc’d units could substitute for washed, but are

more expensive and generally are units that are difficult to find

Assuming Sue is A Rh Negative, which of the following Plasma components

could she safely receive?

• A Rh Positive• B Rh Negative• O Rh Positive• AB Rh Negative• Only the A and AB plasma units lack antibodies that

could react with the antigens on Sue’s Group A RBCs.• Remember that Rh is not a consideration for plasma,

as plasma is not a cellular component.

Which of these plasma products would be appropriate for transfusion to Sue?• Fresh Frozen Plasma• IgA deficient plasma• Irradiated plasma• Washed plasma• Only IgA deficient plasma can be transfused without

causing an anaphylactic reaction.– FFP will have labile coag factors present, but will also have

IgA, unless specifically collected from an IgA deficient donor.

– Irradiation and washing are for cellular products only.

What is the difference between Plasma and Fresh Frozen Plasma (FFP)?

• FFP must be frozen within 8 hours (if manufactured from a Whole Blood collection) or according to the FDA’s guidelines (for an apheresis collection) in order to maintain adequate levels of the labile coag factors.– Factors V and VIII

• Plasma can be prepared from FFP that did not meet the freezing timeline, or FFP that has been thawed and not transfused within 24 hours.– Plasma has the stabile coag factors, but reduced levels of

labile factors.• In most cases, either FFP or Plasma are suitable for

transfusion to restore multiple coag factor deficiencies.

Case Six

• George is a potential bone marrow transplant recipient.

• During treatment to ablate his marrow, he has been supported with multiple packed RBC and platelet concentrate transfusions.

• His last 3 platelet transfusions have not resulted in the expected increase in platelet count.

What term is given to this lack of response to platelet transfusions?

• The patient is said to be refractory to platelets.

Transfusion of which of these components would result the greatest improvement in

the platelet increment?

• ABO group specific Platelets, Pheresis• HLA – matched Platelets, Pheresis• Irradiated platelets (apheresis or

concentrates)• Washed platelets (apheresis or concentrates)

Irradiated Platelets

• Although his immunosuppression may qualify George to receive irradiated cellular components, this will not improve his response to platelets in this case.

• Please choose another component.– ABO group specific Platelets, Pheresis– HLA – matched Platelets, Pheresis– Washed platelets (apheresis or concentrates)

Washed Platelets

• Washing cellular products removes plasma proteins that contribute to anaphylactic and severe allergic transfusion reactions.

• This will not improve George’s response to platelet transfusion.

• Please select another component:– ABO group specific Platelets, Pheresis– HLA – matched Platelets, Pheresis– Irradiated platelets (apheresis or concentrates)

ABO Group Specific Platelets, Pheresis• Transfusing Platelets, Pheresis will limit the number of

donors that George is exposed to (in contrast to pools of platelet concentrates). This can be quite beneficial in preventing refractoriness.

• While providing platelets that are ABO group specific may improve George’s response to platelet transfusion, there is a better choice.

• What is it?– HLA – matched Platelets, Pheresis– Irradiated platelets (apheresis or concentrates)– Washed platelets (apheresis or concentrates)

HLA – matched Platelets, Pheresis• Transfusing Platelets, Pheresis will limit the number of

donors that George is exposed to (in contrast to pools of platelet concentrates). This can be quite beneficial in preventing refractoriness.

• Platelet refractoriness is often caused by HLA antibodies in the recipient destroying the donor platelets. Using platelets that match at the HLA- A and B loci should result in improved platelet counts.– A match = all 4 antigens (2 A’s and 2 B’s) match.– B match = 3 of 4 antigens match; 4th is either a duplicate

(homozygous) or one in which the antibody cross-reacts with one of the patient’s antigens.

– C match = 3 of 4 antigens match; 4th is complete mismatch. This is not a good match and will probably not improve the platelet increment.

What component attribute could have prevented formation of

George’s HLA antibodies?

• Alcohol fractionation• Leukoreduction• Irradiation• Washed• Removal of WBCs by filtration will reduce

exposure to HLA antigens and limit HLA antibody formation, preventing refractoriness.

Attributes

• Alcohol fractionation is used in preparing derivatives from plasma

• Irradiation prevents Transfusion Associated - Graft vs. Host Disease

• Washing removes plasma proteins in order to prevent anaphylactic and severe allergic reactions

Case Seven• Maureen is undergoing a liver transplant.• Near the end of her procedure, the surgeon

would like to transfuse her with a bolus of fibrinogen.

• Which of these blood products should the surgeon order?– Albumin– Cryoprecipitate– FFP– Factor VIII concentrate

Albumin

• This is a plasma derivative that does not contain coagulation factors.

• Please choose another product:– Cryoprecipitate– FFP– Factor VIII concentrate

Factor VIII Concentrate

• This plasma derivative contains Factor VIII only.

• Fibrinogen is NOT in this product.• Please choose a different product:– Albumin– Cryoprecipitate– FFP

FFP

• FFP contains multiple coagulation factors, including fibrinogen.

• However, there are more coag factors in this component than what the recipient requires.

• There is a better choice. What is it?– Albumin– Cryoprecipitate– Factor VIII concentrate

Cryoprecipitate

• The most common use of cryoprecipitate is for replacement of fibrinogen!

If Maureen is AB Rh Positive, which of these cryoprecipitate units would be the best choice for her transfusion?

• AB Rh Negative• A Rh Positive• O Rh Positive• B Rh Positive• All of the above!– Since there are no cells and extremely little plasma in

cryoprecipitate, a recipient of any blood type can receive cryoprecipitate of any blood type.

Case Eight• Mike is scheduled for prostate surgery.• His surgeon has ordered four units of packed

RBCs for him.• These are his type and screen results:

Anti-A Anti-B Anti-D A1 cells B cells Interpretation

2+ 0 4+ W+ 4+ ?????

Screen Cells

IS 37 AHG CC Interpretation

I 0 0 0 3+ ?????

II 0 0 0 3+

III 0 0 0 3+

Mike has an ABO Discrepancy

• What is the most likely cause?– Please click the button in front of your choice.

• Cold alloantibody• Cold autoantibody• Rouleaux• Subgroup of A with anti-A1

Rouleaux• Not likely as none of the screen cells reacted

at the IS phase. – Since rouleaux is due to excess plasma proteins,

all the reactions using the patient’s plasma should have been affected.

• Please make another choice:– Cold alloantibody– Cold autoantibody– Subgroup of A with anti-A1

Cold Alloantibody

• There should have been reactivity with one or more screen cells at the IS phase if this were the source of the discrepancy.

• Please make another selection:– Cold autoantibody– Rouleaux– Subgroup of A with anti-A1

Cold Autoantibody

• No reactivity with the screen cells at the IS phase rules out this possibility.

• Please make another selection:– Cold alloantibody– Rouleaux– Subgroup of A with anti-A1

Subgroup of A with anti-A1

• YES! How would you confirm this?• Test the patient’s RBCs with anti-A1 lectin to

prove that the patient lacks this antigen and could form an antibody to it.

• Repeat the reverse grouping using A2 cells to prove the reactivity with the A1 cells is directed at the A1 antigen and NOT against the A antigen.

Which of the following packed RBC units would be appropriate for

transfusion to Mike?

• A1 Rh Negative

• A2 Rh Positive

• A2B Rh Positive

• O Rh Positive• O Rh Negative• These units lack antigens that would react with

Mike’s antibodies (anti-A1 and anti-B).

Should Mike’s surgeon order Plasma during surgery, which of these Plasma

units would be acceptable?

• A1 Rh Negative• A2 Rh Positive• A2B Rh Positive• O Rh Positive• O Rh Negative• These units do not contain antibodies that would

react with the antigens on Mike’s RBCs.– Remember it is Mike who has anti-A1 in his plasma, not the

plasma donor!

Case Nine

• Willie has anti-Jsb in his serum.• If his physician wants to transfuse packed

RBCs to Willie, which of these sources should be considered?– Autologous blood– Directed donors– Designated Donors– Frozen deglycerolized units

All of these!• Jsb is a high prevalence antigen, so finding antigen negative

blood will be difficult.• If it is possible to plan ahead, Willie should be encouraged

to donate autologous RBCs.– These could be frozen for future use.

• Sometimes when one person in a family is negative for a high prevalence antigen, there are others in the family (i.e. siblings) who are also antigen negative. These individuals may be able to serve as Directed Donors.– If the antiserum to type family members is not readily available,

and the patient’s antibody is strong and you have an adequate quantity, you may screen potential donors with the patient’s serum and then have the donors who appear to be compatible tested for the antigen by a reference laboratory that does have the anti-serum.

Designated Donors

• The American Rare Donor program maintains a database of donors who are Rh null, Bombay phenotype, negative for high prevalence antigens, etc.

• Working with a reference laboratory, it may be possible to recruit a “rare donor” to make a donation for a specific recipient (liquid unit).

• When these rare donor units are not immediately transfused, they are frozen in glycerol; if a liquid unit is not available, a frozen unit may be located.– Frozen, deglycerolized units typically outdate 24 hours

after thawing.

THE ENDHow did you do?