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CHAPTER 138 patient’s Hgb level exceeds 10 g/dL, oxygen delivery and consumption do not

BLOOD PROCUREMENT necessarily increase with RBC transfusions. For patients in the 6 to 10 g/dL Hgb
“gray zone,” the benefit of a transfusion depends upon a patient’s clinical status
AND RED CELL TRANSFUSION and should be weighed against the inherent risks of allogeneic blood.
These risks include adverse reactions, which occur in up to 3 percent of
transfusions. Transfusion-related acute lung injury is the number one cause
of transfusion-related fatalities, and new pathogens causing transfusion-
Jeffrey McCullough, Majed A. Refaai, and Claudia S. Cohn transmitted infections continue to pose a threat to the blood supply.
Transfusion- associated circulatory overload is often not recognized, but is
associated with increased morbidity and prolonged lengths of stay.
SUMMARY As the aging population grows in the United States, the demand for blood
will increase, even as the donor population declines. Patient blood manage-
Blood procurement is a vital national priority that is met in the United States ment efforts are growing in popularity as hospitals grapple with the risks and
by volunteer donors and a pluralistic blood collection program that includes costs associated with transfusion. The implementation of evidence-based prac-
the American Red Cross, independent community blood centers, and hospitals. tice is the best way to benefit patients and minimize the risks of transfusion.
More than 15 million units of whole blood are collected from approximately
10 million donors annually. Recruitment of donors is preceded by a medical
history and limited physical examination. The donated blood is subjected to OVERVIEW OF THE BLOOD BANKING
tests of blood type, red cell antibodies, and infectious agents that may be trans-
mitted by blood transfusion. In some cases, collection of red cells, platelets, SYSTEM IN THE UNITED STATES
leukocytes, or plasma is achieved by hemapheresis. Plasma for the subsequent The United States has a pluralistic system of blood collection rather
manufacture of derivatives such as albumin and intravenous immunoglobulin than the single national system that exists in other developed countries.
is obtained from paid donors by for-profit organizations different from those In the United States during 2011, approximately 15,721,000 units of
that collect whole blood and prepare blood components. The meticulous blood were available for use (Table 138–1). This was a 9 percent decrease
attention to donor risk characteristics and the use of sensitive assays to detect from 2008. Approximately 94 percent of the blood was collected in
infectious agents that may be transmitted by blood have greatly improved the regional blood centers and hospitals collected 7 percent. Less than
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safety of blood. 1percent of the units donated in the United States were autologous
It is widely accepted that red blood cell (RBC) transfusions save lives donations or directed donations, that is, blood given by family or friends
and prevent ischemia-related morbidity in severely hemorrhaging patients for a specific patient. Both autologous and directed donations decreased
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and those with acute anemia (hemoglobin [Hgb] less than 6 g/dL). When a substantially from 2008. Of red cells collected, 97.7 percent of alloge-
neic, 59.0 percent of autologous, and 72.0 percent of directed donor red
cells were transfused to the intended recipient.
All whole blood for transfusion in the United States is donated by
unpaid volunteers; however, costs are incurred in the collection, testing,
Acronyms and Abbreviations: 2,3-BPG, 2,3-bisphophosglyceric acid,; AABB, production, and distribution of blood components. Blood banks pass
American Association of Blood Banks; AHTR, acute hemolytic transfusion reaction; on these costs to hospitals. Some areas of the United States are able to
APACHE II, Acute Physiology and Chronic Health Evaluation II; ATR, allergic transfu- collect more blood than is needed locally and other areas are unable
sion reaction; BCSH, British Committee for Standards in Haematology; BNP, B-type to collect enough blood to meet their local needs. Several inventory-
natriuretic peptide; CI, confidence interval; CMV, cytomegalovirus; CPD, citrate, phos- sharing systems are used to move blood around the United States so as
phate, and dextrose; DAT, direct antiglobulin test; DHTR, delayed hemolytic transfu- to alleviate the shortages.
sion reaction; ESA, erythropoiesis-stimulating agents; FNHTR, febrile non-hemolytic Blood is considered a drug and all aspects of the selection of
transfusion reactions; FOCUS trial, Transfusion Trigger Trial for Functional Outcomes donors, collection, processing, testing, preservation, and dispens-
in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair; G-CSF, granulo- ing are regulated by the FDA. The FDA requirements define the pro-
cyte colony-stimulating factor; GVHD, graft-versus-host disease; Hct, hematocrit; cedures, record-keeping, staff proficiency, specific testing, and donor
Hgb, hemoglobin; HLA, human leukocyte antigen; HNA, human neutrophil antigen; medical requirements that blood banks must follow. Blood banks meet
HPC-A, hematopoietic progenitor cells obtained by apheresis; HPC-C, hematopoietic these requirements using the FDA-defined good manufacturing prac-
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progenitor cells obtained from umbilical cords; HSCT, hematopoietic stem cell trans- tices that are similar to those used by pharmaceutical manufacturers.
plant; IL, interleukin; LDH, lactate dehydrogenase; MOD, multiple-organ dysfunction; Additional standards are formulated by the American Association of
MODS, multiple-organ dysfunction syndrome; NATP, neonatal alloimmune thrombo- Blood Banks (AABB), a voluntary organization that accredits blood banks.
cytopenic purpura; NT-proBNP, N-terminal pro-BNP; PAS, platelets stored in additive
solution; PBM, patient blood management; PEPFAR, President’s Emergency Plan for INTERNATIONAL PRACTICES
AIDS Relief; PINT, Premature Infants in Need of Transfusion; PLS, passenger lympho-
cyte syndrome; PRCA, pure red cell aplasia; RBC, red blood cell; SCD, sickle cell disease; Approximately 107 million units of blood are collected annually world-
TACO, transfusion-associated circulatory overload; TA-GVHD, transfusion-associated wide. Considerable differences in the availability of blood and blood
graft-versus-host disease; TNF-α, tumor necrosis factor-alpha; TRACS, Transfusion components throughout the world are related to the extent of develop-
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Requirements After Cardiac Surgery; TRALI, transfusion-related acute lung injury; ment in the country and the country’s healthcare system. The amount
TRICC, Transfusion Requirements in Critical Care; TRIPICU, Transfusion Strategies for of blood collected in relation to the population ranges from 50 dona-
Patients in Pediatric Intensive Care Units. tions per 1000 population in industrialized countries to five to 15 per
1000 population in developing countries and one to five per 1000

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