72 SECTION II — BLOOD

• Icterus gravis neonatarum: Hyperbilirubine- Table 7-3 Types of cross matching

mia due to haemolysis leads to jaundice Direct (Major) Cross Indirect (Minor) Cross
within 24 h of delivery. In order to com- Matching Matching
pensate for the haemolysis, liver and spleen Donor’s RBCs added to Donor’s plasma added to
get enlarged (hepatosplenomegaly) to recipient plasma. recipient RBCs.
More important as donor Less important because do-
form RBCs.
cells may get agglutinated nor’s plasma gets diluted
• Kernicterus: When bilirubin exceeds by antibodies present with recipient plasma
18 mg/dL, it crosses blood–brain barrier in recipient’s plasma and donor’s antibodies
and destroys brain tissue especially basal (antibody concentration is gets neutralized by freely
more in recipient). available antigens in the
ganglia causing motor deficits. Mental plasma of recipient.
retardation in newborn is also a conse-
quence of HDN.
• Hydrops fetalis: Advanced stage, foetus is • B and AB: A blood group
grossly oedematous (in severe h ­ aemolysis). • A, B and AB: O blood group
Prevention: Administering anti-D antibodies • No agglutination: AB blood group
(Rh immunoglobulin) to pregnant mother at
28–30 weeks of gestation. This antibody prevents CHAPTER RECAPITULATION
sensitisation of the mother to D antigen. Landsteiner law states that when a particular blood group
Treatment: Exchange transfusion of baby. antigen (agglutinogen) is present on red cell membrane of
an individual, the corresponding antibody (agglutinin) will
Replacement of red blood cells of newborn be absent from plasma, but the opposite antibody will be
with Rh-negative blood. This is done because present, and when a particular antigen is absent, the cor-
the Rh-negative blood will not be destroyed responding antibody will be present in plasma. Exception
to Landsteiner law is Rh blood group system. ABO blood
by Rh antibodies circulating in baby’s blood, group is Mendelian dominant and antibody is IgM type,
so bilirubin levels fall. Within few days, baby’s cold antibody. In Rh blood group system, IgG antibodies or
liver starts producing own Rh positive red warm antibodies are present. Blood group system holds im-
cells. Till then anti-Rh antibodies get disap- portance in blood transfusion, pregnancy paternity cases,
medico-legal cases and cell recognition. Bombay blood group
peared from baby’s circulation. is a very rare phenotype in which there is an absence of H
antigen. Hemolytic disease of newborn (erythroblastosis fetalis) is
the disease of foetus and newborn because of agglutination
and haemolysis of foetal red blood cells by macrophages
CROSS MATCHING with release of Hb, due to Rh incompatibility. Cross match-
ing is a technique of matching blood groups, before blood
Technique of matching blood groups before transfusion to determine compatibility between donor and
recipient blood and to prevent mismatched blood transfu-
blood transfusion to determine compatibility sion. In forward blood typing, RBCs are tested against anti-A
between donor and recipient blood and to pre- and anti-B antisera, and in backward or reverse blood typing/
vent mismatched blood transfusion. This is of two grouping, serum of the recipient containing agglutinins is
tested against the RBCs of recipient containing antigens.
types (Table 7-3): direct or major cross match and
indirect or minor cross match.
First of all separate donor and recipient RBCs RECENTLY ASKED QUESTIONS
and plasma. IN EXAMINATION
• Name various blood group systems. Clinical applica-
FORWARD AND BACKWARD BLOOD tions of blood group systems
TYPING/GROUPING • Landsteiner law
• IgG antibody versus IgM antibody
Forward blood typing: RBCs are tested against anti- • Bombay blood group
• Haemolytic disease of newborn or erythroblastosis
A and anti-B antisera. fetalis
Backward or reverse blood typing/grouping: Serum • Cross matching
of the recipient containing agglutinins is tested • Forward grouping versus backward grouping
against the RBCs of recipient containing antigens. • Write about the reason why anti-D is being given to the
mother immediately after birth of Rh positive baby
• Zone phenomenon
If agglutination occurs with
• Explain the basis on which blood grouping is done
• A and AB: B blood group

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 Blood Storage and Blood 8
Transfusion

KNOWLEDGE GOALS
• Blood storage • Blood transfusion
• Blood bank • Blood doping

Citrate phosphate dextrose adenine (CPD-A) is

BLOOD STORAGE
better to use as it preserves 2,3-DPG effectively.
Blood storage is done to preserve blood for long- Cryopreservation: Preservation of cells, tissues
term use. The main aim of blood storage is to pro- which are at risk to damage by cooling at a tem-
vide viable and functional blood components for perature less than zero. This stops enzymatic or
the patients who require blood transfusion. Acid chemical reactions. RBCs can be stored for 10 years
citrate dextrose and citrate phosphate dextrose at −30°C.
adenine both are used in blood banks for blood
storage (Table 8-1). BLOOD STORAGE
Blood is stored for
ROLE OF VARIOUS CONSTITUENTS
• Blood bank
1. Trisodium citrate—anti-coagulant • Tissue typing
2. Dextrose—reduces pH by liberating lactic acid • Plasmapheresis
and improves red cell survival • RBC preservation
3. Phosphate—buffers pH and gives phosphate • Study of enzymatic reactions
substrate
4. Adenine—ATP synthesis, energy provider EFFECTS OF STORAGE ON BLOOD
1. Not suitable for WBCs and platelets because
they remain viable only for 24 h.
Table 8-1 Differentiating features of acid citrate 2. RBCs become spherical because of outward
dextrose (ACD) and citrate phosphate dextrose
adenine (CPD-A) movement of K+ and inward movement of Na+
as a result of decreased Na+-K+ ATPase pump
Features ACD CPD-A activity, which increases water in cell and cell
Components Trisodium citrate Trisodium citrate, becomes spherocytic.
(1.32 g), citric acid phosphate,
3. Fall in pH, decrease in levels of 2,3-DPG, re-
(0.48 g), dextrose dextrose,
(1.40 g), distilled adenine duction in glucose consumption, depletion of
water (100 mL) ATP and building up of lactic acid leading to
pH 5.4 5.6–5.8 loss of red cell viability.
Duration of 21 days 35 days (at 4°C)
storage 4. Increased tendency of haemolysis.
Solution:blood 1.5:10 1:7 5. Loss of stability and flexibility of cell mem-
brane.

73

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74 SECTION II — BLOOD

INDICATIONS FOR BLOOD TRANSFUSION

POINT TO REMEMBER
• Blood loss
Why blood is stored at low temperature?
• Quick Hb restoration
• To reduce bacterial growth. • Exchange transfusion in haemolytic disease of
• To reduce rate of glycolysis which decreases chances newborn (HDN)
of quick fall in pH. • Blood diseases and disorders—aplastic anae-
mia, haemophilia, purpura and other clotting
disorders
• Carbon monoxide poisoning
BLOOD BANK • Autologous blood transfusion
Centre at which blood is collected after blood
donation and is preserved and stored to be used POINT TO REMEMBER
later. Typically, it refers to the branch of a hospital FFP is of less importance in massive blood trans-
where blood is collected, prior tested and then fusion because thrombocytopenia and not the clot-
stored for transfusion purpose. ting factors is the main reason behind pathological
haemorrhage.

BLOOD TRANSFUSION VOLUME EXPANDERS

The life saving measure of transfusing blood Intravenous therapy to maintain fluid volume in
or blood products in one’s circulation, previ- circulation. Volume expanders include crystal-
ously taken from a healthy donor is called blood loids and colloids.
transfusion. Aim of transfusion is to replenish lost • Crystalloid is the solution containing mineral
blood components in the person. Previously, salts and aqueous soluble molecules.
whole blood was given for transfusion, but now-
a-days various blood products (or blood sub- Examples: Normal saline (NS) or physiological
stitutes) are available to be transfused such as saline, ringer’s lactate (RL), 5% dextrose.
RBCs, WBCs, platelets, clotting factors, plasma, • Colloids contribute to colloidal osmotic pressure.
etc (Table 8-2). This is known as blood compo- Examples: Albumin, FFP, gelofusine, hydroxyl
nent therapy. ethyl starch.

Table 8-2 Blood transfusion products and conditions in which these to be given

Blood Transfusion Products Conditions in Which to be Given

Whole blood Anaemia due to blood loss in trauma, surgery or any condition
where individual transfusion products are not available
RBCs only (to prevent circulatory overload): 42 days Iron deficiency anaemia, haemolytic anaemia
(Additives: S, saline; A, adenine; G, glucose; M, mannitol)
WBCs Infections
Platelets (7 days) Coagulation disorders (purpura, Von Willebrand Disease,
dengue)
Coagulation factors (factor VIII, IX) Haemophilia
Cryoprecipitatea (factor II, III, VIII, vWF, fibronectin) Hypofibrinogenemia, surgical bleeding, Von Willebrand
Disease, Disseminated Intravascular Coagulation,
haemophilia, haemorrhage
Plasma Burns, diarrhoea
Plasma expanders (colloids and crystalloids) Dehydration, acute haemorrhagic shock, trauma
Fresh frozen plasmab Deficiency of clotting factors (II, V, VII, IX, X, XI)
Anti-thrombin III deficiency or heparin therapy,
to reverse Warfarin effects in emergency surgery

a
Cryoprecipitate: The frozen blood products obtained by centrifugation of fresh frozen plasma.
b
Fresh frozen plasma (FFP): Fluid phase of human blood which is freezed at −18°C, centrifuged and preserved after 8 h of blood
donation.

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 CHAPTER 8 — Blood Storage and Blood Transfusion 75

2. Transfusion related acute lung injury (TRALI):

POINT TO REMEMBER Acute respiratory distress syndrome occurring
Crystalloids increase volume both in intracellular during or within 6 h of blood transfusion, char-
compartment and interstitium, whereas colloids in- acterised by tachypnoea, dyspnoea, hypoten-
crease the volume in intravascular compartment. sion, fever and cyanosis
3. Circulatory overload
4. Haemochromatosis with massive transfusion
CRITERIA FOR SELECTION OF DONOR 5. Transfusion of blood borne diseases: AIDS, hepati-
tis, syphilis, malaria
• Age between 18–60 years
6. Hypocalcaemia with massive citrate blood trans-
• Healthy donor, not suffering from transmitta-
fusion may lead to tetany
ble diseases
7. Hyperkalemia
• Hb ≥12.5 g%
• Duration between two donations should be *Earliest symptom of mismatched transfusion
≥3 months in males and ≥4 months in females is tightness in chest and suffocation.
• Regular normal pulse rate and body tempera-
ture CONSEQUENCES OF THE ABOVE
COMPLICATIONS
UNIVERSAL DONOR AND UNIVERSAL
Hypotension, renal vasoconstriction and renal
RECIPIENT
tubular damage
• Universal donor—O blood group: As they contain
↓
no antigens on red cells, that is their red cells
Anuria
can be transfused to all the four blood groups.
↓
• Universal recipient—AB blood group: As they have
Uremia
no agglutinins in their plasma which can attack
↓
the transfused blood with A or B antigens and can
Coma
receive blood from any of the four blood groups.
↓
However, these terms are misleading as with the Death
discovery of Rh blood group system, O negative is the
universal donor and AB positive is the universal recipient.

COMPLICATIONS OF MISMATCHED POINT TO REMEMBER

TRANSFUSION Most common cause of mismatched blood transfu-
1. Transfusion-associated body reactions (Fig. 8-1) sion is a clerical mistake.

Figure 8-1 Transfusion associated body reactions.

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76 SECTION II — BLOOD

AUTOLOGOUS BLOOD TRANSFUSION/ CHAPTER RECAPITULATION

AUTOLOGOUS BLOOD DONATION Blood storage is done to preserve blood for long-term use.
(ABD) The main aim of blood storage is to provide viable and
functional blood components for the patients who require
It is also known as intraoperative blood salvage blood transfusion. CPD-A is better to use as it preserves
2,3-DPG effectively. Blood storage is used in blood bank,
(ICS). tissue typing, plasmapheresis, RBC preservation, study
A form of autotransfusion in which the blood of enzymatic reactions. Blood bank is the centre at which
loss or blood spilled during the surgical proce- blood is collected after blood donation and preserved
and stored to be used later for transfusing in those who
dures is recovered and reinfused in the patient. need blood. Typically, it refers to the branch of hospi-
This process is frequently used in cardiovascular tals where blood collected for donation is prior tested
and thoracic surgery (CTVS), as it is beneficial in and then stored for transfusion purpose. Indications for
blood transfusion include blood loss, exchange transfu-
a way that supports bloodless surgery.
sion in haemolytic disease of newborn, blood diseases and
disorder, carbon monoxide poisoning, autologous blood
INDICATIONS transfusion. Complications of mismatched transfusion
include transfusion-associated body reactions such as fe-
• Blood loss >20% expected blood volume of ver, chills, tightness in chest, suffocation, bodyaches, etc.;
patient transfusion-related acute lung injury; circulatory overload;
haemochromatosis; transfusion of blood borne diseases;
• Emergency surgery with risk factors such as hypocalcaemia with massive citrate blood transfusion;
preoperative low haemoglobin hyperkalemia. Autologous blood transfusion is a form of auto
• Rare blood group patients transfusion in which the blood loss or blood spilled during
the surgical procedures is recovered and reinfused in the
• Massive haemorrhage patient. The practice of augmenting RBCs circulation to
improve athletic performance is called blood doping.

BLOOD DOPING RECENTLY ASKED QUESTIONS IN

EXAMINATION
The practice of augmenting RBCs’ circulation
to improve athletic performance is called blood • Blood storage and effects of long-term blood storage
doping. This is done because RBCs contain Hb, • Enumerate various blood transfusion products
which carries oxygen from lungs to the active along with indications of their use
muscles; and the increased red cell concentration • Write about complications of mismatched transfusion
in blood enhances the oxygen carrying capacity • Criteria for ideal donor for blood donation
• Autologous blood transfusion
of the blood, which in turn improves athletic aer-
• Blood doping
obic capacity and performance. • Explain the reason why O positive blood cannot be
Red cells were removed from athlete’s body, repeatedly transfused in a person with AB positive
stored for few weeks and then reinjected in 2–3 blood group
spells few days before the match. • Most common mistake due to which mismatched
Now-a-days, blood doping has been declared illegal transfusion occurs
• Blood substitutes
and being banned by the Olympic Committee.

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