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Research Article

Transfusion

Tropical Journal of Pathology and Microbiology

2020 Volume 6 Number 6 July-August
Publisherwww.medresearch.in

Transfusion pattern of blood products in a blood bank at a tertiary care hospital

Giridharan J.1*, Sarada V.2
DOI: https://doi.org/10.17511/jopm.2020.i06.06

1* Jeevaraj Giridharan, Assistant Professor, Trichy SRM Medical College Hospital and Research Centre, Trichy, Tamil Nadu, India.

2 Sarada V., Professor, Trichy SRM Medical College Hospital and Research Centre, Trichy, Tamil Nadu, India.

Objectives: Blood products in modern-day transfusion practice include, Packed Red Blood Cells, Platelets, Leucocytes, Plasma, Cryoprecipitate, and individual plasma factors. The objective was to study the pattern of usage of various blood products for the commonest clinical indications and to have an overview of the production of blood components. Materials and Methods: In this study, usage of various blood products like Packed Red Blood Cells, Platelet concentrates, Fresh Frozen Plasma, and Cryoprecipitate were studied in the blood bank of Trichy SRM medical college hospital and research center, using blood bank records and correlating with clinical data during the period of June 2015 - June 2020. Observation and result: The pattern of usage among 14,511 units of blood components from June 2015 – June 2020 showed the frequency of usage of Packed Red Blood Cells was more than Fresh Frozen Plasma and whole blood. The usage of whole blood was more than Platelet concentrates and Cryoprecipitate. The most frequently used component was Packed Red blood cells – 7841 units (54%). The second most frequently used component was fresh frozen plasma – 3889 units (26.8%). In the next frequency whole blood- 1955 units (13.5%), platelet concentrates - 797 units (5.5%) and cryoprecipitate – 29 units (0.2%) were used. Conclusion: There has been an appropriate increase in the usage of blood products to meet the clinical demand in treating the patients with an increase in pathological conditions. Specific blood component transfusion should be encouraged for specific indications to reduce non-essential overload to the patients.

Keywords: Blood components, Cryoprecipitate, Fresh Frozen Plasma, Packed Red Blood Cells, Platelets, Usage, Whole blood

Corresponding Author How to Cite this Article To Browse
Jeevaraj Giridharan, Assistant Professor, Trichy SRM Medical College Hospital and Research Centre, Trichy, Tamil Nadu, India.
Email: 		Giridharan J, Sarada V. Transfusion pattern of blood products in a blood bank at a tertiary care hospital. Trop J Pathol Microbiol. 2020;6(6):401-409.
Available From
https://pathology.medresearch.in/index.php/jopm/article/view/471

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2020-07-10 2020-07-30 2020-08-15 2020-08-26
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
No Nil Yes 8%

© 2020 by Jeevaraj Giridharan, Sarada V. and Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Blood transfusion and blood conservation are complementary activities that constitute the clinical arena of transfusion medicine. Blood components can be prepared in a licensed blood bank that has the required space, specialized equipment, storage facilities, and trained personnel. The advent of blood component therapy was by use of factor VIII for hemophiliacs which commenced in the U.K in 1980, prepared by fractionation of human plasma. This is not just for checking infections, but also to minimize the other side effects of blood transfusion [1]. Transfusion of whole blood creates hazards to the patients which were noted in the past few decades. So transfusion of blood components has been considered, to be a low risk and safe procedure [2]. In the United Kingdom and other western countries, whole blood is not used for transfusion for the patients routinely [3,4]. With the development of PVC bags with integral tubing, separation of components can be done safely without risk of infections.

It is processed into various components and only those specifically needed by the patient are issued [4,5,6].

Use of Blood Components ensures added advantages:

  1. Maximized use of one unit of blood for a number of patients with the same unit.
  2. Shelf life of each component is longer than in whole blood.
  3. Better patient care with specific components without danger of overloading/ side effects of other unwarranted components.
  4. Cost-effective blood bank system wherein cost and processing a unit of blood is shared by a number of patients compared to giving whole blood to only one patient/recipient [7-10].

Blood components used in modern-day practice include, apart from whole blood, a variety of other products, like Red Blood Cell products, Leukocyte products, Platelet Concentrates and Plasma as shown in Table-1 [11].

Table-1: Various Blood products.

Red blood cell products Platelet products Leukocyte products Plasma Plasma derivatives
Packed red cells Platelet-rich plasma Granulocyte rich plasma Fresh frozen plasma Factor VIII Concentrate
WBC poor red cells Platelet concentrate Lymphocyte rich plasma Frozen plasma Factor IX Concentrate
WBC depleted red cells Frozen platelets   Cryoprecipitate AT-III Concentrate
Washed red cells     Cryo removed plasma Factor XIII Concentrate
Frozen deglycerolized red cells       Albumin
        IV Immunoglobulin
        Rh Immunoglobulin

Whole Blood: According to the ASA guidelines for whole blood transfusion, acute loss of blood if more than 30% and the patient is at the risk of hemorrhagic shock, the transfusion of whole blood is the component of choice to restore blood volume and oxygen-carrying capacity[12,13,14,15]. Transfusion of whole blood has also been used for anemia in patients. But in modern-day practices replacement of whole blood by individual components plays a vital role to prevent overload to the patients [Table-1].

Packed Red Blood Cells: The guidelines for Packed Red blood cells categorized by ASA depends on the bone marrow production of red blood cells and the destruction of red blood cells. In decreased bone marrow production conditions like Leukemia and Aplastic anemia are included. In decreased red

cell survival conditions like Hemolytic anemia and Thalassemia are included. Packed Red Blood Cells used in bleeding patients are indicated in surgical bleeding and traumatic bleeding [16,17,18]. In anticipated surgical blood loss > 1000 ml or if the patient needs urgent surgery and has hemoglobin < 10g/dl, transfusion is indicated. If there is an acute loss of blood with a reduction of 30-40% of blood volume, transfusion of RBCs along with crystalloids is indicated. Whole blood or packed red blood cells along with crystalloids are indicated for transfusion if there is acute blood loss > 40% of blood volume [19,20].

Other indications for packed red blood cells include, anemia associated with incipient/established cardiac failure or if hemoglobin value < 6 g/dl, patients approaching delivery with hemoglobin value < 7


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g/dl, hereditary hemolytic anemias, and beta-thalassemia major.

Platelet Concentrates: The ASA guidelines categorize the indications of platelet transfusion according to the platelet count. Platelet counts less than 5000/µl due to any comorbid conditions, there is an essential need of an immediate transfusion. If the platelet count range between 5000 – 10000/µl and associated increased risk of bleeding due to hematological malignancies, sepsis, bone marrow aplasia, or a transplant, platelet transfusion indicated. Transfusion of platelet concentrates is needed if the platelet count is between the range of 10000 – 20000 /µl and if bleeding present at mucus membranes, surgical incision, venipuncture site, or presence of scattered petechiae or ecchymosis [22,23]. Other indications include chemotherapy patients with platelet count < 20,000/µl, patients having disseminated intravascular coagulation, and massive transfusion.

Fresh Frozen Plasma (FFP): It is separated from whole blood and is frozen within 6-8 hours of collection. FFP contains plasma proteins and all coagulation factors, including the labile factors V and VIII if stored at - 30°C or below [24,25]. The indications for FFP includes actively bleeding patients, multiple coagulation factor deficiencies as in liver diseases, disseminated intravascular coagulation, coagulopathy in massive transfusion, thrombotic thrombocytopenic purpura (TTP), familial factor v deficiency, deficiency of factors II, VII, IX, X (vitamin K deficiency) [26,27], antithrombin III deficiency and congenital / acquired coagulation factors deficiency.

Cryoprecipitate is precipitated by specific plasma proteins derived from the fresh frozen plasma. The indications for cryoprecipitate for the conditions include hemophilia A, von-Willebrand disease, congenital or acquired fibrinogen deficiency, acquired factor viii deficiency as in disseminated intravascular coagulation or massive transfusion, and factor xiii deficiency [28-31].

Materials and Methods

Setting: Department of Pathology and transfusion medicine, Trichy SRM Medical College Hospital and Research Centre, Trichy.

Duration: June 2015 to June 2020

Type of study: Retrospective study

Sampling Size calculation: Based on previous studies and statistical formula, the sample size was determined with an alpha error of 0.05 and a power of 0.95

Sample size: 14,511

Inclusion criteria: All the blood products utilized at Trichy SRM Medical college hospital during the time of the study period were included in the study.

Exclusion criteria: Blood products that have been discarded and not utilized for transfusion, the data of blood product utilization for which the indications could not be traced.

Data collection procedure: Blood component data were collected retrospectively. Details were recorded, analyzed, and compared with the clinical data to find out the necessary indications for which the components were used.

Data analysis: Categorical variables were expressed in percentages, pie charts, and bar diagrams. The student T-test was applied for calculating statistical significance when data followed nominal distribution. Mann Whitney test applied when data followed non-nominal distribution. Nominal categorical data between the group were compared using the Chi-square test or fisher’s exact test as appropriate. P<0.05 was taken to indicate a statistically significant difference.

Ethical permission: Obtained

Result

Blood Bank of Trichy SRM Medical College Hospital and research center is licensed for the whole blood transfusion by the Department of Drug Controller, India since 2008.

Since then Whole blood transfusion has been in routine practice. Blood Component separation and transfusion has commenced since 2014 when the upgradation on the infrastructure and duly licensed by the Drug Controller of India under the relevant act was done.

The Blood Components that were prepared include Packed Red Blood Cells, Random Donor Platelet Concentrate, Fresh Frozen Plasma, and Cryoprecipitate. The main objective of the present study was to find out the pattern of usage of blood products since 2015 when the license for blood product preparation for specific indications in clinical therapy was done.

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Table-2: Usage of blood products observed during the study period.

Period of Usage (June) Packed Red Blood Cells (PRBC) (Units) Platelet Concentrates (Units) Fresh Frozen Plasma (Units) Cryoprecipitate (Units) Whole blood (Units) Total (Units)
2015 – 2016 457 70 194 Nil 1278 1999 (13.8%)
2016 – 2017 1067 108 222 2 644 2043 (14%)
2017 – 2018 1903 145 867 5 15 2935 (20.2%)
2018 – 2019 2172 221 1112 7 11 3523 (24.2%)
2019 – 2020 2242 253 1494 15 7 4011 (27.8%)
Total (Units) 7841 (54%) 797 (5.5%) 3889 (26.8%) 29 (0.2%) 1955 (13.5%) 14511 (100%)

*One Unit = 350 ml of whole blood/ 250 ml of packed red blood cells/ 220 ml of fresh frozen plasma/ 50 ml of platelet concentrate/ 15 ml of cryoprecipitate.

The total units prepared and utilized for transfusion at Trichy SRM Medical College Hospital from June 2015 to June 2020 was 14,511 units [Table-2].

Among the total units Packed Red blood cells comprises 7841 units (54%), platelet concentratesutilized for transfusion were 797 units (5.5%), total Fresh frozen plasma units utilized were found to be 3889 units (26.8%), Cryoprecipitate utilized for transfusion were found to be 29 units (0.2%), 1955 units (13.5%) of Whole blood have been utilized as well [Table-2].

One unit of Whole blood is about 350 ml and Packed Red Blood cells comprise 250 ml. One unit of platelet concentrates comprises 50ml. A single unit of Fresh frozen plasma and cryoprecipitate comprises 220ml and 15ml respectively.

Table-3: Indications of Packed Red blood cell transfusion observed during the study period.

Indications Units (%)
Traumatic bleeding 1097 14
Surgical bleeding 862 11
Hemolytic anemia 1725 22
Obstetric indications during delivery 1415 18
Aplastic anemia 1254 16
Severe anemia with Hb <3g/dl associated with failure symptoms 235 3
Acute blood loss > 40 ml of blood volume 940 12
Thalassemia 313 4
Total 7841 100

Table-4: Indications observed for Fresh Frozen Plasma transfusion during the study period.

Indications Units Percentage
Active bleeding 1439 37
Liver diseases and coagulation factor deficiencies 855 22
Disseminated intravascular coagulation 233 6
Coagulopathy in massive transfusion 117 3
Thrombotic thrombocytopenic purpura 155 4
Hypovolemia and Poisoning 700 18
Associated Vitamin K and coagulation factor deficiencies 312 8
Congenital coagulation factor deficiencies 78 2
Total 3889 100

Table-5: Indications observed for Whole blood transfusion during the study period.

Indications Units (%)
Anemia which includes all types of anemia except Nutritional anemia 897 46
Traumatic bleeding 341 17
Surgical bleeding 428 22
Exchange transfusion 166 8.8
Liver diseases and coagulation factor deficiencies 78 4
Hypovolemia and poisoning 24 1.2
Obstetric causes during delivery 21 1
Total 1955 100

Table-6: Indications of Platelet Concentrates transfusion observed during the study period.

Indications Units (%)
Platelet count < 5000/µl 143 18
Platelet count – 5000 – 10000/µl with the risk of infections like malaria and dengue and associated bone marrow failure. 223 28
Platelet count – 10000 – 20000 /µl with bleeding manifestations 167 21

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Disseminated intravascular coagulation – with Platelet count < 50,000/µl 111 14
Platelet count - < 70,000/µl with Surgical indications 105 13
Chemotherapy with Platelet count < 20000/µl 48 6
Total 797 100

Table-7: Gender distribution among the population who received a blood transfusion during the study period.

Gender distribution Transfusion received Percentage
Male 8647 66
Female 4454 34
Total 13,101 100

Table-8: Age distribution among the population who received a blood transfusion during the study period.

Age distribution Transfusion received Percentage
<10 years 1048 8
10-19 years 2096 16
20-39 years 3669 28
40-59 years 4323 33
>60 years 1965 15
Total 13,101 100

Age and gender-wise distribution among the population who received blood transfusion irrespective of indications have also been noted in the study. Total patients who received blood transfusion noted during the study were 13,101. Among that 8647 were male patients and 4454 female patients. Hence it is inferred that the male population is receiving blood transfusion more than females [Table-7]. Among the total population (13,101) age-wise distribution, irrespective of indications. 1048 patients (8%) been <10 years of age, 2096 patients were (16%) between 10 – 19 years of age, 3669 patients (28%) were between 20 – 39 years of age. 4323 patients (33%) were between 40- 59 years of age and 1965 patients were > 60 years of age [Table-8].

Discussion

The pattern of usage among 14,511 units of blood components from June 2015 – June 2020 showed the frequency of usage of Packed Red Blood Cells more than Fresh Frozen Plasma and whole blood. The usage of whole blood found to be more than Platelet concentrates and Cryoprecipitate Fig. The most frequently used component was Packed Red blood cells – 7841 units (54%) which is comparable with the previous studies by Rajesh Chandarya et. al (61.1.%) [7]. The second most frequently used component was fresh frozen plasma – 3889 units

(26.8%) followed by whole blood - 1955 units (13.5%), platelet concentrates - 797 units (5.5%), and cryoprecipitate – 29 units (0.2%) [Table-2,3] which is comparable with previous studies by Richa Jain et. al [8], that is Fresh frozen plasma and platelets are frequently used component other than packed red blood cells. There has been an increase in demand and frequency of blood transfusion also noted and documented in the study as 1999 units (13.8%) during 2015 to 2016, 2043 units (14%) during 2016 to 2017, 2935 units (20.2%) during the period of 2017 to 2018, 3532 units (24.2%) during the period of 2018 to 2019 and 4011 units (27.8%) during the period of 2019 to 2020 [Table-2].

The most frequently used component observed during the study was Packed red blood cells - 7841 units (54%) and the yearly increase in demand for transfusion also noted as – 457 units (5.8%) during 2015 to 2016, 1067 units (13.6%) during 2016 to 2017, 1903 units (24.2%) during 2017 to 2018, 2172 units (27.7%) during 2018 to 2019 and 2242 units (28.5%) during 2019 to 2020 [Table-2,3]. Packed red blood cells have been indicated for transfusion most frequently for hemolytic anemias – 1725 units (22%) which is comparable with previous transfusion medicine studies by Luban NLC et. al, Galel S A et. al, that is the usage of packed red blood cells more in hemolytic anemias – 35% [13,14]. For obstetric indications during delivery - 1415 units (18%) have been used. Other common indications observed for which packed red blood cells been utilized were aplastic anemia – 1254 units (16%), traumatic bleeding – 1097 units (`14%), acute blood loss > 40 ml of total blood volume – 940 units (12%), surgical bleeding – 862 units (11%), Thalassemia – 313 units (4%) and severe anemia with Hb< 3 g / dl associated with failure symptoms – 235 units (3%) [Table-4] which is found most indications similar to previous studies of other parts of south India by Dhaka et al [16].

The second most frequently used component was Fresh frozen plasma – 3889 units (26.8%). There has been an increase in demand and transfusion of fresh frozen plasma been observed as – 194 units (5.0%) during 2015 to 2016, 222 units (5.7%) during 2016 to 2017, 867 units (22.3%) during 2017 to 2018, 1112 units (28.6%) during 2018 – 2019 and 1494 units (38.4%) during 2019 to 2020 [Table-2,3]. Among the total units, the most commonly used indication was found to be active bleeding - 1439 units (37%). The second frequent indication observed for which the Fresh frozen


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plasma been used was liver diseases and coagulation factor deficiencies – 855 units (22%). Other indications been observed for fresh frozen plasma transfusion were hypovolemia and poisoning – 700 units (18%), associated vitamin K and coagulation factor deficiencies – 312 units (8%), disseminated intravascular coagulation – 233 units (6%), thrombotic thrombocytopenic purpura – 155 units (4%), coagulopathy in massive transfusion – 117 units (3%) and congenital coagulation factor deficiencies – 78 units (2%) [Table-5] which is comparable with previous transfusion studies by Roberts I, Murray et. al decompensated liver disease for which fresh frozen plasma indicated for transfusion mostly [11].

The third most frequently used blood product been used was found to be whole blood – 1955 units (13.5%). It has been observed that reduction in the whole blood transfusion for therapy during the study period as 1278 units (65.5%) during the period of 2015 – 2016, which has been gradually reduced yearly – 644 units (33.0%) during 2016 to 2017, 15 units (0.7%) during 2017 to 2018, 11 units (0.5%) during 2018 to 2019 and 7 units (0.3%) during the period of 2019 to 2020 [Table-2, 3]. Its evident that blood component therapy replaces the whole blood transfusion in preventing overload and complications to the patient. The most common indication for which whole blood transfused was anemia – 897 units (46%) which is comparable with previous whole blood transfusion studied by Hass et.al, Jeanne A. et al, Petz, Lawrence, et al – severe anemia in various parts of world makes the need for emergency transfusion in life-threatening conditions [20,23,27] Other common indications for whole blood transfusion been observed was surgical bleeding – 428 units (22%), traumatic bleeding 341 units (17%), exchange transfusion – 166 units (8.8%), liver diseases and coagulation factor deficiencies – 78 units (4%), hypovolemia and poisoning – 24 units (1.2%) and obstetric indications during delivery – 21 (1%) [Table-6] which is comparable with Dhaka et al, that is major indications of whole blood in anemia – 52% (17).

Platelet concentrates were found to be the fourth frequently used blood component – 797 units (5.5%) which are comparable with previous transfusion medicine studies by Opelz G – 10% [28]. There has been an increase in demand and transfusion of platelet concentrates been observed as – 70 units (8.7%) during 2015 to 2016, 108 units (13.5%) during 2016 to 2017, 345 units

(18.4%) during 2017 to 2018, and 221 units (27.7%) during 2018 – 2019 and 253 units (31.7%) during 2019 to 2020. [Table-2,3]. The most common indication for which platelet transfusion been done to patients was found to be platelet count – 5000 – 10,000/ µl with the risk of infections and bone marrow failure – 223 units (28%). Other common indications have been observed were patients having platelet count 10000-20000/ul with bleeding manifestations – 167 units (21%), platelet count < 5000/ ul – 143 units (18%), disseminated intravascular coagulation – 111 units (14%), platelet count < 70,000/ ul with surgical indications – 105 units (13%) and chemotherapy patients < 20000/ul – 48 units (6%) [Table-7] which is found to have similar indications of platelet transfusion with platelet count range of 5000 – 70,000/ul from the studies by Dhaka et al, Robinson J (17, 30).

The less frequently used component was Cryoprecipitate – 29 units (0.2%). No transfusion have been found during 2015 to 2016, 2 units (7.0%) were used during 2016 to 2017, 5 units (17.2%) during 2017 to 2018 and 7 units (24.1%) during 2018 – 2019 and 15 units (51.7%) during 2019 to 2020 [Table-2,3]. The most common indications noted for cryoprecipitate transfusion were von Willebrand disease and hemophilia A (factor VIII deficiency) – 21 units (72%). For rapid surgical wound healing, fibrinogen rich concentrate has been used (38%) which is comparable with the previous results by Dhaka et al, Rowley SD (17,31) – most part of cryoprecipitate transfusion indicated in von Willebrand disease and hemophilia A (75%). With awareness creation and frequent clinical collaborations, and increased demand has been observed. With age and gender-specific findings, it is been inferred that patients who received critical blood transfusion were between 20 – 39 years of age which is comparable with previous age-specific transfusion studies by Petz, Lawrence [27] where most transfusion been done in adult age groups been found.

Limitations

The study limits to analyze the pattern of usage of major four blood components which have been prepared in the blood bank. Further, the study to be extended to all other minor blood components of plasma protein derivatives and leukocytes to know the overall pattern of usage. And also through this study, analysis of the most common indications for each component irrespective of the age of the


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recipients for transfusion was done. Hence further extension of this study can be made for age-specific indications for which the blood components are used to minimize immediate as well as long term sequelae of transfusions.

Conclusion

There has been an increase in the usage of blood products yearly to meet the clinical demand in treating patients with various morbidities. Instead of whole blood transfusion, specific blood component transfusion is encouraged for specific indications to reduce non-essential overload to the patients, which has been achieved in our department of transfusion medicine.

This is observed clearly in the present study. Preparation of blood component which has been frequently used (packed red cells) in our tertiary care hospital is encouraged which is also evident from the present study. Prevalence of anemia, thrombocytopenia with the risk of infections like malaria and dengue, von Willebrand disease, and trauma among the population nearby have been noted as other conditions worth in-depth study in relation to transfusion practice, in the patients from this area.

What does the study add to the existing knowledge

The highest achievement in this new modern era in the field of Transfusion medicine is the separation of one unit of blood into its various components for the transfusion so that more Blood component transfusions must be encouraged than the whole blood transfusion, to minimize avoidable transfusion reactions, allogeneic sensitization, volume overload and to use one unit of blood to save many lives. This simple study can be done in all the institutions to know the common indications and pattern of usage of blood components of blood transfusion in various geographical areas to promote the economy of voluntarily donated blood to save many lives with one unit of blood.

Author’s contribution

Dr. Jeevaraj Giridharan; Concept, manuscript preparation

Dr. V. Sarada: Manuscript preparation, data analysis

Acknowledgments

The authors are thankful to the Chairman, the Dean, and the Medical superintendent, Institutional scientific and ethical committee for the approval to conduct the study.

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