Erythrocytes

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Erythrocytes

General	Erythrocyte choice and compatibility studies
Indication	Undesirable effects
Method of registration	Erythrocyte products
Storage conditions

General
Erythrocytes contain haemoglobin, and transport oxygen and CO2 in the blood back and forth from tissues and the lungs. Erythrocyte products can be prepared from a whole blood extraction by centrifuging whole blood and removing the plasma, as well as most of the leukocytes and thrombocytes, as buffy coat. Storage fluid (Saline Adenine Glucose Mannitol, or SAGM) is then added to the erythrocytes. This results in the final product having a haematocrit level between 0.50 and 0.65 L/L. The erythrocyte suspension is then filtered over a leukocyte removing filter.

Erythrocytes, leukocytes removed, in storage fluid, is the standard product where transfusion is indicated for the treatment of anaemia.

Volumes usually smaller than those reported below are available for the benefit of transfusions to children. Because these erythrocyte concentrations are prepared by dividing one donation, repeated transfusions can be performed with exposure to a smaller number of donors.

Indication
Erythrocytes are administered in order to elevate the oxygen carrying capacity of the recipient. As a rule, erythrocytes are only given under the guidance of complaints and symptoms that are partly determined by the age and the cardiovascular/pulmonary status of the patient.

Chronic anaemia:
Most patients can easily tolerate a low Hb concentration (to 4 – 5 mmol/l). It is not perforce necessary to correct the Hb concentration in these patients.

Substantial blood loss:
Loss of 20 – 25% of the blood volume can be replaced with, for example, colloidal fluids.
The oxygen carrying capacity is optimal at an Hb concentration of 5 – 6 mmol/l. With more substantial blood loss (and dependent upon the clinical situation and guided by the Hb concentration), erythrocytes are given alongside the volume supplementation.

Before, during and after an operation:
As long as the factors that co-determine oxygen transport (such as circulation, ventilation and oxygenation of the blood) are kept under control during and after anaesthesia, a Hb concentration of 5 – 6 mmol/l is optimal for good tissue oxygenation. This boundary is somewhat higher in patients with heart or pulmonary anomalies.

Neonates:
Erythrocyte transfusion is indicated in the following circumstances:

in the first 24 hours post partum with a capillary haemoglobin concentration < 8.0 mmol/L and clinical phenomena of anaemia;
during artificial respiration and a haemoglobin concentration < 8.0 mmol/L;
during administration of oxygen and a haemoglobin concentration < 7.0 mmol/L;
stable premature infants younger than 4 weeks and with a haemoglobin concentration < 6.0 mmol/L;
stable premature infants older than 4 weeks and with a haemoglobin concentration < 4.5 mmol/L.

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Method of administration

Precaution
It is advisable that every blood product be administered as rapidly as possible after arrival at the Department.
Where possible, blood products should be administered during the day (for the monitoring of transfusion reactions).

Blood product checks and identity
The unit must always be carefully inspected prior to the transfusion to ensure it is intended for the patient concerned. At the bedside, check the identity and the ABO-blood group/Rhesus (D) factor of the patient, the data on the label of the blood product concerning ABO-blood group/Rhesus (D) factor, the expiry date, product code, and, if available, the result of the compatibility study. Before the administration the transfusion bag should also be visually checked for leakage and the presence of coagulants, contaminants or discolouration.

Administration system
An infusion for the administration of blood products may only be filled with physiological saline (NaCl 0.9%). A filter of 170 – 200 µm must be included in the administration system. For the administration, mix with blood products made decoagulant with citrate. NEVER use Ringers lactate or other calcium-containing fluids.
Medicines must never be added to blood products or be connected to the infusion. A double lumen catheter (whereby the blood product is administered by the other line) must be employed when central lines are used for parenteral feeding.
If no separate infusion line is available, then an already inserted line can be used (after pre-rinsing and after-rinsing with physiological saline) to transfuse erythrocytes or plasma. Thrombocytes must never be transfused with a used administration system.
The administration system must be thoroughly rinsed with physiological saline both before and after every unit.
Micro-aggregate filter (40 µm) may not be included in the administration system with thrombocyte transfusions.
A peripheral administration system must preferably be replaced within 6 hours after the last transfusion.

Administration rate
The infusion rate for all blood products must be slow during the first 10 minutes. The patient must be continuously observed for the occurrence of transfusion reactions with this. If these do not occur, then the administration rate can be adjusted as follows:

Erythrocytes are administered dependent upon the clinical condition; for stable patients approximately 300 mL in 1 to 2 hours (3 – 5 mL/kg/hour for children), faster with substantial blood loss, slower for patients with compromised cardiac function.
Thrombocytes are administered as rapidly as possible (approximately 300 mL in 15 to 30 minutes).
Plasma may be administered equally rapidly (approximately 300 mL in 15 to 30 minutes).
A blood product may be administered until a maximum of 6 hours after needling.

Warming of erythrocyte products
The warming of erythrocyte products is exclusively indicated for extremely rapid transfusions (for adults, 50 – 100 ml/min).
An especially validated blood warming apparatus, by which the supply hose is warmed, must be used for this. It is not allowed to warm the bag with erythrocytes by immersing it in warm water.

Thawing of plasma
Fresh frozen plasma must be thawed at a maximum of 37 oC in equipment that is intended (validated) for such use. It should be occasionally turned during the thawing. If a water bath is used for the thawing, then the plasma must first be wrapped in a plastic liner. Plasma must NEVER be thawed in a domestic microwave oven. The plasma should be administered as rapidly as possible (maximum of 2 hours) after thawing.

Handling transfusion reactions
If cold chills, fever, blood pressure reductions, anaphylactic shock or shortness of breath occurs, then the blood product must be disconnected and the infusion transferred over to physiological saline in order to keep open the access to the bloodstream. A physician must then be alerted.
See transfusion reactions. Transfusion reactions must always be reported to the blood transfusion laboratory (transfusion reaction form).

Administration
The patient’s dossier must indicate which the product code of the administered blood products, as well as the unit identification numbers. The dossier must also indicate which transfusion reactions may possibly have arisen. Under statutory requirements, these data must be stored for a minimum of 10 years.

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Storage conditions
In order to preserve quality and to prevent bacterial growth, erythrocytes must be stored at a temperature of 2 - 6 ºC and, unless otherwise indicated, have a shelf life of 35 days. Erythrocytes, which must be warmed to above 10 oC after storage, may not be again stored and must be either administered within 24 hours or otherwise destroyed.
For the performance of compatibility studies, Erythrocytes should not be kept outside the refrigerator for more than about a half an hour. The storage temperature must be guaranteed during transport, unless the product is exclusively administered for performing compatibility studies.

Erythrocyte choice and compatibility studies
Erythrocytes must preferably always be identical, and at least compatible, with the ABO and Rhesus (D) of the recipient.
The choice of ABO blood group and Rhesus (D) of donor erythrocytes for children younger than 3 months is dependant upon the ABO blood group, and any possible irregular antibodies, of the mother. The blood groups must be compatible with those of the child and the mother.

ABO blood group choice for donor erythrocytes in the first three months of life:

Child	Mother	Donor erythrocytes
0	0,A or B	0
A	A or AB	A or 0
A	0 or B	0
B	B or AB	B or 0
B	0 or A	0
AB	AB	AB, A, B or 0
AB	A	A or 0
AB	B	B or 0

Compatibility studies
The following compatibility studies must be completed prior to the administration of erythrocyte products:

Determination of the ABO blood group and Rhesus (D) antigen of the recipient. If possible, at least in duplicate from independently extracted blood samples.
Determination of the presence or absence of irregular erythrocyte antibodies in the recipient (also in the mother during the first 3 months of the infant’s life) with a technique that is at least as sensitive as the indirect anti-globulin test with albumin. The test erythrocytes must fulfil precisely described specifications. The following antigens must be homozygotically present in a minimum of one of the test erythrocyte suspensions: C, c, D, E, e, Fya, Fyb, Jka, Jkb, M, S, s. The K antigen must be at least heterozygotically present. If the patient has received blood products during the last 3 months, is (was) pregnant, or if one of these circumstances can not be excluded with certainty, then the result of the antibody screening is of limited validity to a maximum of 72 hours after extraction of the cross-matched blood.
A complete cross-matching test or the so-called ‘Type and Screen method’. For the Type and Screen method, the ABO blood group of the patient and donor must be checked with an in vitro test or the compatibility of ABO blood group should be checked with a ‘short’ cross-matching test of patients’ serum/plasma and donor’s erythrocytes in saline.

A complete cross-matching test (including anti-globulin phase) is always necessary with:

newborns (to 3 months of age); there must always (also) be cross-matching with the serum/plasma from the mother;
patients that had (ever) shown clinically relevant irregular erythrocyte antibodies:
recipients of organ transplants until 3 months after transplantation;
patients after allogenic stem cell transplantation;
intra-uterine transfusions;
patients with inherited or acquired anomalies in erythrogenesis for which frequent transfusions of erythrocytes must be given (for example, thalassemia major and [congenital] hypoplastic anaemia).

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Cross-matched blood
The sample tube for determining the blood group, antibody screening and/or cross-matching test must exhibit the following details: name, date of birth and/or registration number of the patient, date and time of extraction, and initials of the person who has extracted the blood. The cross-matched blood may not be extracted more than 72 hours before the compatibility studies are held.

Positive cross-matching test or antibody screening
If the antibody screening of cross-matching test is found to be positive, then the specific nature of the erythrocyte antibodies must be established.
If clinically relevant irregular antibodies against erythrocytes have ever been demonstrated, then there must subsequently be exclusive administration of erythrocytes that are negative for the concerned antibody(ies).

Recommendation for prevention of immunisation by c, E and K.
Even though there is no national policy in this regard, Sanquin recommends that the only erythrocytes that should be administered to girls and women up to the age of 44 (as well as patients that have inherited anomalies in erythrogenesis and are dependent upon transfusions for their entire lives) are those that are compatible with the antigens c, E and K.

Blood types other than ABO Rhesus (D)
Erythrocytes can be typed for antigens other than ABO and Rhesus (D) (for example, for the CcEe or other blood group systems such as Kell, Duffy, Kidd, NMSs, P, etc.).
The type is printed on the product label only when this typing has been performed twice on independent samples from the donor.
With Rhesus (D) negative donors, the D assay is likewise performed twice with an indirect anti-globulin test (IAT) before this is printed upon the label (D-IAT -).

Undesirable effects
Undesirable effects that may occur during or after a transfusion include:
fever with or without cold chills, acute or delayed haemolytic transfusion reactions, circulatory overfilling, bacterial contamination, Graft Versus Host Disease, Transfusion Related Acute Lung Injury, Post-transfusion Purpura, overfilling, accumulation of iron and infectious diseases.

Erythrocyte products

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