blood transfusion

Britannica Concise Encyclopedia: blood transfusion

Transfer of blood taken from one person into the circulation of another to restore blood volume, increase hemoglobin levels, or combat shock. Once the blood-group antigens and antibodies (see ABO blood-group system, Rh blood-group system) were discovered, blood typing of donors and recipients rendered transfusion safe. In exchange transfusion, all or most of the blood is removed and replaced with another's blood. Undesirable reactions to transfusion are not uncommon.

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World of the Body: blood transfusion

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Blood, moved between bodies, has long been thought to rejuvenate its recipient. Though transfusion ‘proper’ — moving blood directly into a recipient's veins with the intention of healing a variety of afflictions — might have awaited William Harvey's early-seventeenth-century work on blood's circulation, a long and colourful tradition of moving blood preceded it. Homer's Odysseus, for example, fed the blood of sacrificed animals to the shades of Hades to ‘substantiate’ them, enabling them to communicate with the living. In another blood ritual, the early-sixteenth-century Hungarian countess Elizabeth Bathory became obsessed by the idea that the blood of virgins would preserve her youth and beauty. She enticed local girls to her castle, where she hung them in metal cages and stuffed them into iron maidens, allowing the blood that flowed from their slowly pierced bodies to bathe her.

The perception of blood's movement as regenerative is tied to complex cultural conceptions of blood itself. Blood has long been used as a metaphor for identity: family (‘blood is thicker than water’) ; class (‘blue blood’) ; race (‘black blood’) ; nationality (‘red-blooded American’) ; opposition (‘bad blood’). It has also been seen as the intangible carrier of the ‘vital spirit’ that animates animal bodies. Some Hippocratic physicians dubbed it the highest of the four humours, the formative substance of body and character. Similarly, blood's movement between bodies has carried and extended these meanings: a sharing of the self and an extension of life. Christians believe communion wine to represent (and, for Roman Catholics, to be) Christ's blood. Drinking it prepares the faithful to enter into eternal life and at the same time strengthens the communal Christian identity.

Early history

The first recorded efforts to transfuse blood directly into living veins came in England in 1665, where Richard Lower transfused blood between dogs. In 1667, Jean-Baptiste Denis, of France's Académie des Sciences, successfully transfused lamb's blood into a human. It has been suggested these transfusions were conducted as much to see if science could correct the unhappy consequences of humanity's fall from Grace as to examine the empirical possibilities of blood's circulation. These experiments were cut short after one of Denis' patients died shortly after receiving a transfusion. A subsequent trial exonerated Denis, but banned transfusion without prior approval of the Académie de Médecine. The French Parliament, the Royal Society, and the Catholic Church subsequently issued general prohibitions against transfusion. For 150 years, it fell from orthodox medical practice.

Transfusion was reintroduced by the London physiologist and obstetrician, James Blundell, in 1818. Blundell conducted several transfusions between 1818 and 1834, many of which he considered to have been successful. It is probable that Blundell was inspired to attempt transfusion by his somewhat vitalistic ideas about blood and by a broader cultural interest in reanimation of the ‘apparently dead’ — evident in scientific movements such as galvanism and resuscitation, and in novels such as Mary Shelley's Frankenstein (1818). Blundell came to espouse two main guidelines for transfusion: it was only to be used on women near death from uterine haemorrhage, and only humans could serve as donors. Thus failures were often attributed to the patient being beyond the reach of medical intervention; successes were presented as dramatic resurrections. Further, human donors, unlike their seventeenth century animal predecessors, resisted having their arteries opened for attachment to the recipient's veins. Blundell devised apparatus for ‘indirect’ transfusion to move venous blood through cups and syringes (‘Impellors’ and ‘Gravitators’), and thence into the patient.

Indirect transfusion inevitably led to another problem: clots. Clotted blood gummed up the pipes of instruments and the veins of humans — to the detriment of both. In 1821, J-L. Prévost and J. B. A. Dumas, then working in Geneva, proposed defibrination as a solution. Defibrination entailed whipping the blood with a fork or twig so as to collect the fibrin on the whipping object and prevent the blood from coagulating as rapidly. Some, believing fibrin to be a mere waste material, seized upon the procedure, but others opposed it, convinced that fibrin was central to the formation of living tissue. Direct, or ‘immediate’, transfusion was proposed as a way to circumvent these problems. Suggested independently in London by J. H. Aveling and in Geneva by J. Roussel in 1864, immediate transfusion relied on india-rubber tubes and silver cannulae to carry blood, as it had in the seventeenth century, directly from donor to recipient.

In nineteenth-century Britain, transfusion was primarily the domain of obstetricians, though, from the 1870s, surgeons began to use it as well. By the 1880s, however, physiologists began to question the necessity of using blood to replace blood loss. Guided by blood pressure measurements and histological investigations, they increasingly saw the circulation in material terms: as an enclosed, fluid system that contained cellular parts. From this less vitalistic perspective, lost blood might be replaced by fluids that would refill the circulatory system while avoiding nasty coagulation. By the early twentieth century, blood transfusion had generally been replaced by saline infusion. In Britain, surgery textbooks referred to blood transfusion (once again) as a quaint relic of medical history.

Recognition of blood types

It was at this historical moment, with transfusion distinctly out of medical favour, that the Viennese pathologist, and later Nobel prizewinner, Karl Landsteiner, was conducting his famous studies demonstrating that certain antibodies in human serum were not pathological, but normal. He showed that human blood naturally occurred in three different ‘types’. A fourth was discovered in 1902 by his colleagues Decastello and Sturli. These four blood types were later given the names by which they are known today: A, B, O, and the fourth type, AB. The discovery demonstrated that the exchange of human blood carried with it the potential danger of haemolysis: if a recipient's blood plasma contained antibodies to the donor's red blood cells, the cells would clump or disintegrate (haemolyse), leading to discomfort at best and death at worst. It therefore offered a plausible explanation of transfusion's past failures. Landsteiner's studies did not, however, promptly usher in the modern period of transfusion. Relegated to serological realms, and with medical practitioners generally using saline, blood-typing was virtually ignored by clinicians. Indeed, even after transfusion was again ‘rediscovered’ a few years later, it was rediscovered in ignorance of Landsteiner's work. ‘Typing’ blood for transfusion was not generally regarded as essential until late in World War I; and, even then — given the pressing nature of the circumstances — it was not necessarily conducted. Further, Landsteiner himself abandoned his typing work for decades, only returning to it in the 1920s. In 1939-40, he helped lead the investigations that proved the existence of rhesus types: shedding light upon why even the most careful interwar typing sometimes failed to prevent a haemolytic reaction.

Twentieth century developments

From the turn of the century, the Americans had taken the lead in transfusion. On the basis of experiments on shock, American surgeon and physiologist George Washington Crile became convinced that saline could not, in fact, replace lost blood effectively. In 1905, he began to conduct transfusion experiments on humans. Using a technique pioneered by the French surgeon and future Nobel laureate Alexis Carrel, Crile connected a donor's artery to a recipient's vein, allowing direct transfusion of blood between humans. Americans began practising transfusion with some regularity before the War, even recruiting a growing stream of ‘donors’ who were paid for their blood.

World War I proved a turning point. Transfusion was imported, first by Canadians, then by US medical officers. Further encouraged by the simplicity of transfusion undertaken with sodium citrate as an anticoagulant — now, blood could be collected in a bottle, moved from room to room, and even held for a while — British and French surgeons at the front increasingly turned to blood to treat soldiers suffering from the collapse they then called ‘wound shock’. (The Germans, too, performed transfusions.) Moreover, the British and Americans undertook a special ‘anti-shock campaign’ from the summer of 1917. ‘Resuscitation Wards’ were staffed by specially-trained shock teams; in them, collapsed soldiers were given the blood of their lightly-injured brothers-in-arms in an effort to stabilize them for further surgical intervention. It was here that many British sceptics were won over to the benefits of blood transfusion.

Blood donors and blood banks

In the early 1920s, a number of hospitals assembled their own small donor panels: even using the citrate method, donors still had to go to hospital to give blood for each emergency. Initially, they were paid for their blood. Discontented with this adhoc system, some prominent British doctors began calling for a centralized donor service. In 1921, Percy Lane Oliver, master-organizer and Honorary Secretary of the local Camberwell division of the British Red Cross, started just such a system. Moreover — and, more remarkably — his system relied wholly on unpaid donors, at a time when some American hospitals were paying donors up to $100 for a pint. The fledgling voluntary service grew rapidly, being taken up in 1926 by the greater British Red Cross and providing donors to all London's voluntary hospitals by the early 1930s. Under Oliver's firm hand, the new London Blood Transfusion Service also shaped the rights and responsibilities of the modern voluntary blood donor. The London model was quickly adopted throughout Britain and thereafter by national Red Cross and other organizations in a host of other countries. Debate as to the relative merits of paid and voluntary donor systems, and their implied conceptions of blood as commodity or gift, continues to inform the direction of today's donor programmes throughout the world.

Yet, it is difficult to imagine how the current pervasiveness of donor programmes, and, indeed, of transfusion itself, could exist without the addition of another innovation: blood banking, or, the cold-storage-based exchange of blood. Though initially developed at the Rockefeller Institute in 1916 and applied on a small scale on the French front in 1918, cold storage was virtually ignored until the 1930s, when it was used in Moscow to preserve cadaver blood for later transfusion. The unconventional donors attracted as much attention as did the possibilities of the procedure. Cold storage was given further dramatic introduction to the broader world during the Spanish Civil War, where the international array of doctors attending to its casualties pooled, cooled, then distributed donated blood to the wounded. Back in the US, Chicago's Cook County Hospital applied the process of cold storage to its own blood exchange system in 1937, creating what is thought to have been the first civilian ‘blood bank’. In this odd interplay of war and peace, the place of blood banking (as well as of transfusion more generally) was firmly established in World War II.

Blood products

During the war, the newly-developed procedure of separating the plasma from the blood cells and drying the plasma helped fuel longstanding debates about the best fluids to transfuse in various medical conditions. Dried plasma was indefinitely storable and far more portable than blood. Rehydrated, it appeared to be more effective for example in the treatment of burns than did whole blood. Gradually, a kind of division of labour for blood components was articulated. Today, whole blood is used in relatively few circumstances — for example, to treat severe haemorrhage, and in heart bypass procedures. Red blood cells in suspension are the alternative in operative procedures, and are given to patients with severe anaemia; platelets or white blood cells can be separately extracted and given to those suffering from a lack of them. Whole plasma is transfused to treat fluid and protein loss, and plasma is also used to obtain particular components which are lacking from the blood in certain disorders. The procedure known as plasma ‘fractionation’, developed in the mid 1930s, has given rise to a host of ‘biologicals’ for infusion. These include albumin, for treating patients with burns; Factors VIII and IX, which help coagulate the blood of men with haemophilia; and immunoglobulins, to provide specific antibodies to infections such as tetanus or chickenpox, or ‘Anti-D’ which is given to rhesus-negative mothers to prevent damage to their rhesus-positive babies.

Blood's processing and transportation was facilitated, and the safety of its infusion improved, by the development of plastic ‘blood packs’ from the early 1950s. Now a familiar icon of transfusion, these packs were adopted elsewhere, but they did not become the official containers of Britain's blood until 1975, replacing glass bottles.

Despite this medicalization, blood has in many ways retained its privileged cultural status. Citing Old Testament prohibitions against consuming blood, Jehovah's Witnesses forbid the transfusion of blood into their members. More generally, blood's movement between bodies continues to rest upon donor systems that must grapple with the social meanings of a fluid at once intensely personal, medically essential, and commercially valuable. Indeed, blood's extensive processing has sometimes complicated the task of voluntary donor groups, whose staff must persuade donors that the pharmaceutically-produced powders and potions derived from their blood remain direct ‘gifts’ to those in dire medical need — not sold at a profit to ‘outside’ systems.

Current problems

Typing has become more complex, with the recognition of groups within groups, and along with this has come more sophisticated laboratory ‘matching’. A hazard that remains, and that requires meticulous screening of donors, is transmission by blood and its products of viral infections, notably hepatitis and HIV. This was tragically brought to public attention in the fate of haemophiliacs in the 1980s. Treated with biologicals derived from large pools of donated blood, many became infected with HIV and later died of complications from AIDS. The medical, ethical, and legal implications of AIDS for blood transfusion are still being determined. While efforts to clone or create synthetic blood continue, transfusion remains bloody — and, as such, intimately linked to its long cultural history.

— Kim Pelis

Bibliography

Gunson, H. H. and Dodsworth, H. (1996). Fifty years of blood transfusion. Transfusion Medicine, 6, supplement 1.
Keynes, G. (1922). Blood transfusion. Henry Frowde, London.
Titmuss, R. M. (1970). The gift relationship: from human blood to social policy. George Allen and Unwin, London

Dental Dictionary: blood transfusion

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The administration of whole blood or a component such as packed red cells to replace blood lost through trauma, surgery, or disease.

Sports Science and Medicine: blood transfusion

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The intravenous administration of red blood cells or related blood products that contain red blood cells. See also blood doping.

Columbia Encyclopedia: blood transfusion

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blood transfusion, transfer of blood from one person to another, or from one animal to another of the same species. Transfusions are performed to replace a substantial loss of blood and as supportive treatment in certain diseases and blood disorders. When whole blood is not needed, or when it is not available, plasma, the fluid of the blood without the blood cells, can be given. Alternately, such components of the blood as red cells, white cells, or platelets may be given for particular deficiencies. Blood substitutes, which are under development, are expected ultimately to ease the chronic short supply of blood and to alleviate certain storage and compatibility problems.

In whole-blood transfusions, the blood of the donor must be compatible with that of the recipient. Blood is incompatible when certain factors in red blood cells and plasma differ in donor and recipient; when that occurs, agglutinins (i.e., antibodies) in the recipient's blood will clump with the red blood cells of the donor's blood. The most frequent blood transfusion reactions are caused by substances of the ABO blood group system and the Rh factor system. In the ABO system, group AB individuals are known as universal recipients, because they can accept A, B, AB, or O donor blood. Persons with O blood are sometimes called universal donors, since their red cells are unlikely to be agglutinated by the blood of any other group. In the Rh factor system, agglutinins are not produced spontaneously in an individual but only in response to previous exposure to Rh antigens, as in some earlier transfusion. Transfusion reactions involving incompatibility eventually cause hemolysis, or disruption of donor cells. The resulting liberation of hemoglobin into the circulatory system, causing jaundice and kidney damage, can be lethal.

In addition to providing for the compatibility of blood groups in transfusion, it is necessary to determine that the donor's blood is free of organisms that might cause syphilis, malaria, serum hepatitis, or HIV, the virus believed to cause AIDS. Allergic reactions to transfusions may occur in cases where allergic antibodies have been transmitted from the donor's blood, possibly because of some type of food recently ingested by the donor. These problems have increased the popularity of autologous transfusions, transfusions using a person's own blood, which has been donated ahead of time. See blood bank.

Health Dictionary: blood transfusion

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The injection of blood received from a donor into the bloodstream of another individual having a compatible blood type. A person may need a blood transfusion if a great deal of blood has been lost through surgery or trauma.

If the blood supply is contaminated, diseases such as hepatitis and AIDS can be passed to someone who receives a blood transfusion.

Wikipedia: Blood transfusion

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Blood transfusion is the process of transferring blood or blood-based products from one person into the circulatory system of another. Blood transfusions can be life-saving in some situations, such as massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia caused by a blood disease. People suffering from hemophilia or sickle-cell disease may require frequent blood transfusions. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood.

History

Early attempts

The first historical attempt at blood transfusion was described by the 15th-century chronicler Stefano Infessura. Infessura relates that, in 1492, as Pope Innocent VIII sank into a coma, the blood of three boys was infused into the dying pontiff (through the mouth, as the concept of circulation and methods for intravenous access did not exist at that time) at the suggestion of a physician. The boys were ten years old, and had been promised a ducat each. However, not only did the pope die, but so did the three children. Some authors have discredited Infessura's account, accusing him of anti-papalism.^[1]

World War II syringe for direct interhuman blood transfusion

Beginning with Harvey's experiments with circulation of the blood, more sophisticated research into blood transfusion began in the 17th century, with successful experiments in transfusion between animals. However, successive attempts on humans continued to have fatal results.

The first fully documented human blood transfusion was administered by Dr. Jean-Baptiste Denys, eminent physician to King Louis XIV of France, on June 15, 1667.^[2] He transfused the blood of a sheep into a 15-year old boy, who survived the transfusion.^[3] Denys performed another transfusion into a labourer, who also survived. Both instances were likely due to the small amount of blood that was actually transfused into these people. This allowed them to withstand the allergic reaction. Denys' third patient to undergo a blood transfusion was Swedish Baron Bonde. He received two transfusions. After the second transfusion Bonde died.^[4] In the winter of 1667, Denys performed several transfusions on Antoine Mauroy with calf's blood, who on the third account died.^[5] Much controversy surrounded his death. Mauroy's wife asserted Denys was responsible for her husband's death. But Mauroy's wife was accused of causing his death. Though it was later determined that Mauroy actually died from arsenic poisoning, Denys' experiments with animal blood provoked a heated controversy in France.^[6] Finally, in 1670 the procedure was banned. In time, the British Parliament and even the pope followed suit. Blood transfusions fell into obscurity for the next 150 years.

First successful transfusion

Christian Zagado examined the effects of changes in blood volume on circulatory function and developed methods for cross-circulatory study in animals, obviating clotting by closed arteriovenous connections. His newly devised instruments eventually led to actual transfusion of blood.

"Many of his colleagues were present. towards the end of February 1665 [when he] selected one dog of medium size, opened its jugular vein, and drew off blood, until . . . its strength was nearly gone . Then, to make up for the great loss of this dog by the blood of a second, I introduced blood from the cervical artery of a fairly large mastiff, which had been fastened alongside the first, until this latter animal showed . . . it was overfilled . . . by the inflowing blood." After he "sewed up the jugular veins," the animal recovered "with no sign of discomfort or of displeasure."

Lower had performed the first blood transfusion between animals. He was then "requested by the Honorable [Robert] Boyle . . . to acquaint the Royal Society with the procedure for the whole experiment," which he did in December of 1665 in the Society’s Philosophical Transactions. On 15 June 1667 Denys, then a professor in Paris, carried out the first transfusion between humans and claimed credit for the technique, but Lower’s priority cannot be challenged.^{[citation needed]}

Six months later in London, Lower performed the first human transfusion in Britain, where he "superintended the introduction in [a patient’s] arm at various times of some ounces of sheep’s blood at a meeting of the Royal Society, and without any inconvenience to him." The recipient was Arthur Coga, "the subject of a harmless form of insanity." Sheep’s blood was used because of speculation about the value of blood exchange between species; it had been suggested that blood from a gentle lamb might quiet the tempestuous spirit of an agitated person and that the shy might be made outgoing by blood from more sociable creatures. Lower wanted to treat Coga several times, but his patient refused. No more transfusions were performed. Shortly before, Lower had moved to London, where his growing practice soon led him to abandon research. [1]

The first successes

The science of blood transfusion dates to the first decade of the 19th century, with the discovery of distinct blood types leading to the practice of mixing some blood from the donor and the receiver before the transfusion (an early form of cross-matching).

In 1818, Dr. James Blundell, a British obstetrician, performed the first successful blood transfusion of human blood, for the treatment of postpartum hemorrhage. He used the patient's husband as a donor, and extracted four ounces of blood from his arm to transfuse into his wife. During the years 1825 and 1830, Dr. Blundell performed 10 transfusions, five of which were beneficial, and published his results. He also invented many instruments for the transfusion of blood. He made a substantial amount of money from this endeavour, roughly $50 million (about $2 million in 1827) real dollars (adjusted for inflation).^{[citation needed]}

In 1840, at St George's Hospital Medical School in London, Samuel Armstrong Lane, aided by Dr. Blundell, performed the first successful whole blood transfusion to treat hemophilia.

George Washington Crile is credited with performing the first surgery using a direct blood transfusion at the Cleveland Clinic.

Many patients had died and it was not until 1901, when the Austrian Karl Landsteiner discovered human blood groups, that blood transfusions became safer. Mixing blood from two individuals can lead to blood clumping or agglutination. The clumped red cells can crack and cause toxic reactions, which can have fatal consequences. Karl Landsteiner discovered that blood clumping was an immunological reaction which occurs when the receiver of a blood transfusion has antibodies (A, B, both A & B, or neither) against the donor blood cells. Karl Landsteiner's work made it possible to determine blood groups (A, B, AB, O) and thus paved the way for blood transfusions to be carried out safely. For this discovery he was awarded the Nobel Prize in Physiology or Medicine in 1930.

Development of blood banking

The modern era

Following Bogdanov's lead, the Soviet Union set up a national system of blood banks in the 1930s. News of the Soviet experience traveled to America, where in 1937 Bernard Fantus, director of therapeutics at the Cook County Hospital in Chicago, established the first hospital blood bank in the United States. In creating a hospital laboratory that preserved and stored donor blood, Fantus originated the term "blood bank". Within a few years, hospital and community blood banks were established across the United States.

In the late 1930s and early 1940s, Dr. Charles R. Drew's research led to the discovery that blood could be separated into blood plasma and red blood cells, and that the plasma could be frozen separately. Blood stored in this way lasted longer and was less likely to become contaminated.

Another important breakthrough came in 1939-40 when Karl Landsteiner, Alex Wiener, Philip Levine, and R.E. Stetson discovered the Rhesus blood group system, which was found to be the cause of the majority of transfusion reactions up to that time. Three years later, the introduction by J.F. Loutit and Patrick L. Mollison of acid-citrate-dextrose (ACD) solution, which reduces the volume of anticoagulant, permitted transfusions of greater volumes of blood and allowed longer term storage.

Carl Walter and W.P. Murphy, Jr., introduced the plastic bag for blood collection in 1950. Replacing breakable glass bottles with durable plastic bags allowed for the evolution of a collection system capable of safe and easy preparation of multiple blood components from a single unit of whole blood. Further extending the shelf life of stored blood was an anticoagulant preservative, CPDA-1, introduced in 1979, which increased the blood supply and facilitated resource-sharing among blood banks.

As of 2006, there were about 15 million units of blood transfused per year in the United States.^[8]

Precautions

Compatibility

The key importance of the Rh group is its role in Hemolytic disease of the fetus and newborn. When an Rh negative mother carries a positive fetus, she can become immunized against the Rh antigen. This usually is not important during that pregnancy, but in the following pregnancies she can develop an immune response to the Rh antigen. The mother's immune system can attack the baby's red cells through the placenta. Mild cases of HDFN can lead to disability but some severe cases are fatal. Rh-D is the most commonly involved red cell antigen in HDFN, but other red cell antigens can also cause the condition. The "positive" or "negative" in heard blood types such as "O positive" is the Rh-D antigen.

Transfusion Transmitted Infections

A number of infectious diseases (such as HIV, syphilis, hepatitis B and hepatitis C, among others) can be passed from the donor to recipient.

Among the diseases than can be transmitted via transfusion are:

HIV-1 and HIV-2
Human T-lymphotropic virus (HTLV-1 and HTLV-2)
Hepatitis C virus
Hepatitis B
Treponema pallidum
Malaria
Chagas Disease
variant Creutzfeldt-Jakob Disease or "Mad Cow Disease" has been shown to be transmissible in blood products. No test exists for this, but various measures have been taken to reduce risks.

When a person's need for a transfusion can be anticipated, as in the case of scheduled surgery, autologous donation can be used to protect against disease transmission and eliminate the problem of blood type compatibility. "Directed" donations from donors known to the recipient were a common practice during the initial years of HIV. These kinds of donations are still common in developing countries.

Processing of blood prior to transfusion

Donated blood is usually subjected to processing after it is collected, to make it suitable for use in specific patient populations. Examples include:

Component separation: red cells, plasma and platelets are separated into different containers and stored in appropriate conditions so that their use can be adapted to the patient's specific needs. Red cells work as oxygen transporters, plasma is used as a supplement of coagulation factors, and platelets are transfused when their number is very scarce or their function severely impaired. Blood components are usually prepared by centrifugation.
Leukoreduction, also known as Leukodepletion is the removal of white blood cells from the blood product by filtration. Leukoreduced blood is less likely to cause alloimmunization (development of antibodies against specific blood types), and less likely to cause febrile transfusion reactions.
- Chronically transfused patients
- Potential transplant recipients
- Patients with previous febrile nonhemolytic transfusion reaction
- Patients with hereditary immune deficiencies
- Patients receiving blood transfusions from relatives in directed-donation programs
- Patients receiving large doses of chemotherapy, undergoing stem cell transplantation, or with AIDS (controversial).

Neonatal transfusion

To ensure the safety of blood transfusion to pediatric patients, hospitals are taking additional precaution to avoid infection and prefer to use specially tested pediatric blood units that are guaranteed negative for Cytomegalovirus. Most guidelines recommend the provision of CMV-negative blood components and not simply leukoreduced components for newborns or low birthweight infants in whom the immune system is not fully developed.^[9] These specific requirements place additional restrictions on blood donors who can donate for neonatal use. Neonatal transfusions are usually top-up transfusions, exchange transfusions, partial exchange transfusions. Top-up transfusions are for investigational losses and correction of mild degrees of anemias, up to 5-15 ml/kg. Exchange transfusions are done for correction of anemia, removal of bilirubin, removal of antibodies and replacement of red cells. Ideally plasma-reduced red cells that are not older than 5 days are used.^[10]

A. If an exchange transfusion is necessary, compatible blood must be ordered. If a severely affected ( i.e. hydropic) infant with Rh hemolytic disease is anticipated at birth, it may be necessary to have blood available in the nursery prior to the delivery. The request should be for O negative packed red blood cells of the specific volume needed and of the appropriate CMV status. This blood may be utilized in any one of the following ways: 1. The RBC's may be given as a simple transfusion (with or without additional Plasmanate) while stabilization of the infant is accomplished. 2. The RBC's may be used for a partial exchange transfusion to acutely elevate the hematocrit without changing the blood volume in a severely anemic baby.

B. When the need for an emergency, complete exchange transfusion is virtually certain, arrangements can be made in advance for O negative whole blood or O negative PRBC's resuspended in fresh frozen plasma.

C. For double-volume exchange transfusions for hemolytic disease of the newborn or for hyperbilirubinemia without hemolysis, the blood used will be packed cells (type O, Rh specific for the infant) resuspended to the desired hematocrit in compatible fresh frozen plasma.

D. A partial exchange transfusion is often done for polycythemia (see section on polycythemia).

II. Although the standard anticoagulant (CPD) is acidic, the blood need not be buffered. If the infant is severely acidemic, consult the staff neonatologist.

III. If possible, the infant should be NPO and the stomach contents aspirated prior to the procedure.

IV. The exchange transfusion should be done under a radiant warmer using sterile technique.

V. The donor blood should be warmed using the blood warmer to a temperature not exceeding 37oC.

VI. The infants blood pressure, respiratory rate, heart rate and general condition should be monitored during the exchange transfusion according to standard nursing protocol.

VII. If the serum bilirubin concentration is at a dangerous level and the blood for exchange transfusion is not yet ready, consider priming the infant with 1 gram/kg (4 ml/kg) of a 25% solution of salt-poor albumin to bind additional bilirubin and keep it in the circulation until the exchange can be accomplished..

VIII. The umbilical vein catheter should be inserted until there is free flow of blood immediately prior to starting the exchange transfusion. See section on placement of umbilical catheters for technique. The exchange transfusion should not be done through an umbilical artery line unless the UAC is used only for blood withdrawal with simultaneous replacement through the umbilical vein or peripheral IV. At the beginning of the exchange transfusion, the first blood sample withdrawn should be sent for 1)total and direct bilirubin; 2) hemoglobin and hematocrit; 3) glucose; and 4) calcium.

IX. Use the "exchange transfusion kit", which contains catheters, stopcocks, waste bag, and calcium gluconate.

X. Ideally, blood (or colloid in the event of a partial volume exchange) should be infused through a peripheral vein at a rate equal to blood withdrawal from the UVC. If the "push-pull" (single catheter) technique is utilized, no more than 5 ml/kg body weight should be withdrawn at any one time.

XI. The exchange volume is generally twice the infant's blood volume, (generally estimated to be 80 ml/kg). The total volume exchange should not exceed one adult unit of blood (450-500 ml). A standard two-volume exchange will remove approximately 85% of the red cells in circulation before the exchange and reduce the serum indirect bilirubin level by one-half. The exchange of blood should require a minimum of 45 minutes.

XII. The need for giving supplemental calcium is controversial. If used give 0.5 to 1.0 ml of 10% calcium gluconate IV, after each 100 ml of exchange blood. Monitor heart rate for bradycardia.

XIII. At the end of an exchange transfusion blood should be sent for sodium, glucose, calcium, total and direct bilirubin, and hemoglobin and hematocrit.

XIV. At the end of an exchange transfusion, the umbilical vein catheter is usually removed. In the event of a subsequent exchange, a new catheter can be inserted.

XV. Hypoglycemia often occurs in the first or second hour following an exchange transfusion. It is therefore necessary to monitor blood glucose levels for the first several hours after exchange.

XVI. The serum bilirubin concentration rebounds to a value approximately halfway between the pre- and post- exchange levels by two hours after completing the exchange transfusion. Therefore, the serum bilirubin concentration should be monitored at two to four hours after exchange and subsequently every three to four hours.

XVII. Feedings may be attempted two to four hours after the exchange transfusion.

Terminology

The terms type and screen are used for the testing that (1) determines the blood group (ABO compatibility) and (2) screens for alloantibodies.^[11] It takes about 45 minutes to complete (depending on the method used). The blood bank technologist also checks for special requirements of the patient (eg. need for washed, irradiated or CMV negative blood) and the history of the patient to see if they have a previously identified antibody.

A positive screen warrants an antibody panel/investigation. An antibody panel consists of commercially prepared group O red cell suspensions from donors that have been phenotyped for commonly encountered and clinically significant alloantibodies. Donor cells may have homozygous (e.g. K+k-), heterozygous (K+k+) expression or no expression of various antigens (K-k+). The phenotypes of all the donor cells being tested are shown in a chart. The patient's serum is tested against the various donor cells using an enhancement method, eg Gel or LISS. Based on the reactions of the patient's serum against the donor cells, a pattern will emerge to confirm the presence of one or more antibodies. Not all antibodies are clinically significant (i.e. cause transfusion reactions, HDN, etc). Once the patient has developed a clinically significant antibody it is vital that the patient receive antigen negative phenotyped red blood cells to prevent future transfusion reactions. A direct antiglobulin test (DAT) is also performed as part of the antibody investigation.^[12]

Once the type and screen has been completed, potential donor units will be selected based on compatibility with the patient's blood group, special requirements (eg CMV negative, irradiated or washed) and antigen negative (in the case of an antibody). If there is no antibody present or suspected, the immediate spin or CAC (computer assisted crossmatch) method may be used.

In the immediate spin method, two drops of patient serum are tested against a drop of 3-5% suspension of donor cells in a test tube and spun in a serofuge. Agglutination or hemolysis in the test tube is a positive reaction and the unit should not be transfused.

If an antibody is suspected, potential donor units must first be screened for the corresponding antigen by phenotyping them. Antigen negative units are then tested against the patient plasma using an antiglobulin/indirect crossmatch technique at 37 degrees Celsius to enhance reactivity and make the test easier to read.

If there is no time the blood is called "uncross-matched blood". Uncross-matched blood is O-positive or O-negative. O-negative is usually used for children and women of childbearing age. It is preferable for the laboratory to obtain a pre-transfusion sample in these cases so a type and screen can be performed to determine the actual blood group of the patient and to check for alloantibodies.

Procedure

Blood transfusions can be grouped into two main types depending on their source:

Homologous transfusions, or transfusions using the stored blood of others. These are often called Allogeneic instead of homologous.
Autologous transfusions, or transfusions using the patient's own stored blood.

Donor units of blood must be kept refrigerated to prevent bacterial growth and to slow cellular metabolism. The transfusion must begin within 30 minutes after the unit has been taken out of controlled storage.

Blood can only be administered intravenously. It therefore requires the insertion of a cannula of suitable caliber.

Before the blood is administered, the personal details of the patient are matched with the blood to be transfused, to minimize risk of transfusion reactions. Clerical error is a significant source of transfusion reactions and attempts have been made to build redundancy into the matching process that takes place at the bedside.

A unit (up to 500 ml) is typically administered over 4 hours. In patients at risk of congestive heart failure, many doctors administer a diuretic to prevent fluid overload, a condition called Transfusion Associated Circulatory Overload or TACO. Acetaminophen and/or an antihistamine such as diphenhydramine are sometimes given before the transfusion to prevent other types of transfusion reactions.

Blood donation

Main article: Blood donation

Blood is most commonly donated as whole blood by inserting a catheter into a vein and collecting it in a plastic bag (mixed with anticoagulant) via gravity. Collected blood is then separated into components to make the best use of it. Aside from red blood cells, plasma, and platelets, the resulting blood component products also include albumin protein, clotting factor concentrates, cryoprecipitate, fibrinogen concentrate, and immunoglobulins (antibodies). Red cells, plasma and platelets can also be donated individually via a more complex process called apheresis.

In developed countries, donations are usually anonymous to the recipient, but products in a blood bank are always individually traceable through the whole cycle of donation, testing, separation into components, storage, and administration to the recipient. This enables management and investigation of any suspected transfusion related disease transmission or transfusion reaction. In developing countries the donor is sometimes specifically recruited by or for the recipient, typically a family member, and the donation immediately before the transfusion.

Risks to the recipient

Main article: Transfusion reaction

There are risks associated with receiving a blood transfusion, and these must be balanced against the benefit which is expected. The most common adverse reaction to a blood transfusion is a febrile non-hemolytic transfusion reaction, which consists of a fever which resolves on its own and causes no lasting problems or side effects.

Hemolytic reactions include chills, headache, backache, dyspnea, cyanosis, chest pain, tachycardia and hypotension.

Blood products can rarely be contaminated with bacteria; the risk of severe bacterial infection and sepsis is estimated, as of 2002, at about 1 in 50,000 platelet transfusions, and 1 in 500,000 red blood cell transfusions.^[13]

There is a risk that a given blood transfusion will transmit a viral infection to its recipient. As of 2006, the risk of acquiring hepatitis B via blood transfusion in the United States is about 1 in 250,000 units transfused, and the risk of acquiring HIV or hepatitis C in the U.S. via a blood transfusion is estimated at 1 per 2 million units transfused.^{[citation needed]} These risks were much higher in the past before the advent of second and third generation tests for transfusion transmitted diseases. The implementation of Nucleic Acid Testing or "NAT" in the early 2000s has further reduced risks, and confirmed viral infections by blood transfusion are extremely rare in the developed world.

Transfusion-associated acute lung injury (TRALI) is an increasingly recognized adverse event associated with blood transfusion. TRALI is a syndrome of acute respiratory distress, often associated with fever, non-cardiogenic pulmonary edema, and hypotension, which may occur as often as 1 in 2000 transfusions.^[14] Symptoms can range from mild to life-threatening, but most patients recover fully within 96 hours, and the mortality rate from this condition is less than 10%.^[15]. Although the cause of TRALI is not clear, it has been consistently associated with anti HLA antibodies. Because anti HLA strongly correlate with pregnancy, several transfusion organisations (Blood and Tissues Bank of Cantabria, Spain, National Health Service in Britain) have decided to use only plasma from men for transfusion.

Other risks associated with receiving a blood transfusion include volume overload, iron overload (with multiple red blood cell transfusions), transfusion-associated graft-vs.-host disease, anaphylactic reactions (in people with IgA deficiency), and acute hemolytic reactions (most commonly due to the administration of mismatched blood types).

Transformation from one type to another

Scientists working at the University of Copenhagen reported in the journal Nature Biotechnology in April 2007 of discovering enzymes, which potentially enable blood from groups A, B and AB to be converted into group O. These enzymes do not affect the Rh group of the blood.^[16]^[17]

Objections to blood transfusion

Objections to blood transfusions may arise for personal, medical, or religious reasons. For example, Jehovah's Witnesses object to blood transfusion primarily on religious grounds - they believe that blood is sacred; although they have also highlighted possible complications associated with transfusion.

Animal blood transfusion

Veterinarians also administer transfusions to animals. Various species require different levels of testing to ensure a compatible match. For example, cats have 3 known blood types, cattle have 11, dogs have 12, pigs 16 and horses have 34. However, in many species (especially horses and dogs), cross matching is not required before the first transfusion, as antibodies against non-self cell surface antigens are not expressed constitutively - i.e. the animal has to be sensitized before it will mount an immune response against the transfused blood.

The rare and experimental practice of inter-species blood transfusions is a form of xenograft.

Blood transfusion substitutes

Main article: Blood substitutes

As of 2009, there are no widely utilized oxygen-carrying blood substitutes for humans; however, there are widely available non-blood volume expanders and other blood-saving techniques. These are helping doctors and surgeons avoid the risks of disease transmission and immune suppression, address the chronic blood donor shortage, and address the concerns of Jehovah's Witnesses and others who have religious objections to receiving transfused blood.

A number of blood substitutes are currently in the clinical evaluation stage. Most attempts to find a suitable alternative to blood thus far have concentrated on cell-free hemoglobin solutions. Blood substitutes could make transfusions more readily available in emergency medicine and in pre-hospital EMS care. If successful, such a blood substitute could save many lives, particularly in trauma where massive blood loss results. Hemopure, a hemoglobin-based therapy, is approved for use in South Africa.

References

^ {"Vicars of Christ" - Peter de Rossa}
^ http://www.heart-valve-surgery.com/heart-surgery-blog/2009/01/03/first-blood-transfusion
^ "This Month in Anesthesia History". http://www.anesthesia.wisc.edu/AHA/Calendar/June.html. Retrieved 2009-06-15.
^ http://www.pbs.org/wnet/redgold/innovators/bio_denis.html
^ "Mollison’s Blood Transfusion in Clinical Medicine" by H.Klein, D. Anstee (2005), p.406
^ http://www.pbs.org/wnet/redgold/innovators/bio_denis.html
^ Bernice Glatzer Rosenthal. New Myth, New World: From Nietzsche to Stalinism, Pennsylvania State University, 2002, ISBN 0-271-02533-6 pp. 161-162.
^ Laura Landro (2007-01-10). "New rules may shrink ranks of blood donors". Wall Street Journal. http://www.post-gazette.com/pg/07010/752655-28.stm.
^ "Red blood cell transfusions in newborn infants: Revised guidelines". Canadian Paediatric Society (CPS). http://www.cps.ca/english/statements/fn/fn02-02.htm#What%20type%20of%20RBCs%20should%20be%20used. Retrieved 2007-02-02.
^ KM Radhakrishnan , Srikumar Chakravarthi , S Pushkala, J Jayaraju (2003 Aug). "Component therapy". Indian J Pediatr 70 (8): 661–6. doi:10.1007/BF02724257. PMID 14510088.
^ Blood Processing. University of Utah. Available at: http://library.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BBPROC.html. Accessed on: December 15, 2006.
^ D. Harmening, Modern Blood Banking and Transfusion Practices, 4th Ed. 1999
^ Blajchman M (2007). "Incidence and significance of the bacterial contamination of blood components". Dev Biol (Basel) 108: 59–67. doi:10.2478/v10036-007-0007-1. PMID 12220143.
^ Silliman C, Paterson A, Dickey W, Stroneck D, Popovsky M, Caldwell S, Ambruso D (1997). "The association of biologically active lipids with the development of transfusion-related acute lung injury: a retrospective study". Transfusion 37 (7): 719–26. doi:10.1046/j.1537-2995.1997.37797369448.x. PMID 9225936.
^ Popovsky M, Chaplin H, Moore S (1992). "Transfusion-related acute lung injury: a neglected, serious complication of hemotherapy". Transfusion 32 (6): 589–92. doi:10.1046/j.1537-2995.1992.32692367207.x. PMID 1502715.
^ Liu QP, Sulzenbacher G, Yuan H, Bennett EP, Pietz G, Saunders K, Spence J, Nudelman E, Levery SB, White T, Neveu JM, Lane WS, Bourne Y, Olsson ML, Henrissat B, Clausen H (2007). "Bacterial glycosidases for the production of universal red blood cells". Nat Biotechnol 25: 454. doi:10.1038/nbt1298. PMID 17401360.
^ "Blood groups 'can be converted'". BBC news. 2007-04-02. http://news.bbc.co.uk/1/hi/health/6517137.stm.

Academic resources

Transfusion, ISSN: 1537-2995 (electronic) 0041-1132 (paper)

v • d • e Transfusion medicine

General concepts	Apheresis (plasmapheresis, plateletpheresis, leukapheresis) · Blood transfusion · Coombs test (direct and indirect) · Cross-matching · Exchange transfusion · International Society of Blood Transfusion · Intraoperative blood salvage · ISBT 128 · Transfusion reactions

Blood group systems · Blood types	ABO · Chido-Rodgers · Colton · Cromer · Diego · Dombrock · Duffy · Gerbich · GIL · Hh · Ii · Indian · JMH · Kell (Xk) · Kidd · Knops · LW · Lewis · Lutheran · MNS · OK · P · Raph · Rh · Scianna · T-Tn · Xg · Yt · Other

Blood products	Blood donation · Blood substitutes · Cryoprecipitate · Platelets · Plasma · Red blood cells · Whole blood · Fresh frozen plasma

External links

Five Myths on Blood Transfusions, an information campaign by the New South Wales Government.
Blood Transfusion Indications, information provide by Maharashtra State Blood Transfusion Council.

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