Professional Documents
Culture Documents
Transfusion
Transfusion
transfusion procedures
The clinician is responsible for:
Name of person
taking the blood
sample together with
date and signature.
Name must be
stamped or CLEARLY
written.
Patient identification band
All patients receiving a transfusion must wear
an identity band.
phlebotomy practices.
1. Collecting blood for pre-transfusion testing requires critical
attention to identification process
Dispatch Form/Sample
3ml sample in EDTA tube is required for process of
blood group and antibody screen
Test performed
Blood grouping
Antibody investigations
It is advisable to sent a blood sample at the time of
booking for an elective procedure !!!
Elective surgery
Rh negative units are limited and for emergency use
For elective surgery 7 working days notice is required
Special Conditions
Blood compatibility form
Patient particulars must match in compatibility label, compatibility form,
patient’s folder and identity band
Unit number and blood group must match on blood bag label,
compatibility label and compatibility form
Checking of labels
Bedside check is vital.
Identity check
The major risks from transfusion are
associated with unsafe clinical
transfusion practices and
inappropriate blood product
transfusion
How to transfuse
blood and blood products
Must be ABO and RhD group specific with the recipient.
Requires compatibility testing except if group is unknown.
TIME FOR TRANSFUSION
Transfusion must be within 30 minutes from
DESCRIPTION receiving the unit.
Volume -300+- 30ml
Hb - >45g/unit MEDICATION
Hct - 35%-45%
Do not add or push any medication
INDICATIONS
- Acute blood loss with
hypovolemia ABO COMPATIBILITY
- Exchange transfusion
TRANSPORTATION
Blood collection box with ice
Recipient Group Compatible Group
packs.
FILTERS Unknown Unmatch O ( low titre
Administered through a A&B)
standard
O O
(170-200µm)blood filter.
COMPATIBLE A A
INTRAVENOUS SOLUTIONS B B
Whole
NaCl Blood
Rh COMPATIBILITY
0.9%
RhDABpositive units to RhD positiveAB
recipients
PUMPS and WARMERS RhD positive to RhD negative recipients if Rh
Acceptable for use if ordered. negative blood stocks are low
RED CELL
DESCRIPTION ADMINISTRATION
volume- 150-200ml Must be ABO and RhD group specific.(1st option)
Hb - > 45g/dl Compatible ABO and RhD group (2nd option)
Hct – 50%-70% Requires compatibility testing
DOSE TIME TRANSFUSED
4ml/kg in adults raises the Hb Transfuse within 30 minutes once received from blood bank.
concentration by 1g/dl or Hct by Transfusion must be completed within 4 hours.
3%
A dose of 10-15ml/kg in neonates
Patient ABO
MEDICATION Donor Group Donor Group
increases the Hb by 3g/dl and Hct st
by 60%. Group 1 Option 2nd Option
Do not add any medication with red cell components .
INDICATIONS A COMPATIBILITYA
ABO O
Replacement of red cells in B B O
anemic patients. AB AB A,B,O
TRANSPORTATION O O -
Blood collection box with
Red Blood
ice packs. Patient Rh Donor Rh Donor Rh
FILTEr 1st Option 2nd Option
InfuseCells
using a standard blood set
with filter.(170-200µm). Positive
Rh Positive
COMPATIBILITY Negative
Negative Negative Positive
PUMPS and WARMERS ( elderly males and females
Acceptable for use upon non child bearing age)
physician’s order.
Platelet ABO Selection Chart
Platelets
Patient ABO Donor ABO Specific Donor non-ABO Specific
Group ( 1st option) ( 2nd option)Selection order
INDICATION
A A AB,B,O(low titre anti-
Treatment and Prevention of A&B)
bleeding.
B B AB,A,O
DOSE
AB AB A,B,O
4-6 random platelets (one adult O O B,A,AB
dose)should raise the platelet count *1 adult dose is equivalent to 4-6 Random platelets
by 20-40x109/L TIME OF INFUSION
TRANSPORTATION Should be transfused as soon as possible within a period 30 minutes.
Collected in blood boxes not chilled
ADMINISTRATION.
FILTERS
A standard blood administration set. Requires ABO identification of the recipient.
PUMPS ABO specific transfusion is preferred but not required.
Infusion devise not recommended, Always use a fresh new set.
Flush with normal saline if continue to use for red cell or FFP.
Rh COMPATIBILITY
If RhD positive platelets are given to RhD negative patients, Rh Immuno Globulin (Anti-D) should be given.
One vial (250i.u) of anti globulin will cover 4-5 adult doses of platelets within 6 weeks.
All apheresis platelets and pooled platelets are leucodepleted and irradiated
Plasma (FFP)
INDICATION
Replacement of coagulation factor DESCRIPTION
deficiency. Volume- 200ml-300ml
Disseminated Intravascular Contains factor VIII level >70% of normal fresh plasma level
Coagulation (DIC) ADMINISTRATION
DOSE Must normally be ABO compatible.
10-15ml/kg ABO identification of recipient is required
No compatibility testing required.
MEDICATION Infuse using a standard blood administration set.
No medication should be added. Transfusion should be completed within 30 minutes to one
PUMPS hour.
Acceptable for use. Return the units to blood bank if not used within 30 minutes.
TRANSPORTATION
Blood collection boxes without ice packs.
Patient Donor Group Donor
Group
Rh
ABO
ABO group (1st option) (2nd option)
Plasma may be transfused without regard
COMPATIBILITY
A A AB to Rh type.
B B AB
AB AB -
O O A,B,AB
COMPATIBILITY
Cryoprecipitate If possible use ABO compatible products.
May be transfused without regard to Rh type.
DESCRIPTION
Volume – 10ml-20ml ADMINISTRATION
Contains- Factor VIII-80- No compatibility testing required
100iu/pack After thawing infuse as soon as possible
Fibrinogen 150- Transfuse using a standard blood administration set
300mg/pack Must be transfused within 30 minutes to one hour
Must be completed within 4 hours of thawing .
INDICATIONS
Accquired Coaglulopathies
Disseminted Intravascular
Coaglulopathies (DIC)
Plasma Products for one DIC cycle
DOSE 1. 6 Cryoprecipitate
One unit/7-10kg body wt 2. 4 Platelets
One adult dose will increase the 3. 2 FFP
fibrinogen levels by about 1g/dl.
Preparation of plasma for use
TRANSPORTATION
Blood collection boxes without FFP, Cryoprecipitate and Cryosupernatant are thawed for 20-30
ice packs minutes at 37oC in a water bath.
Once thawed plasma cannot be refrozen again.
General Transfusion Practices
• When to transfuse.
• Rate to transfuse.
• Devices used for transfusion.
• Time limit for transfusion.
General Practices in TransfusionADMINISTRATION SETS
OPTIMAL TIME FOR TRANSFUSION - All blood and blood components must be
Elective transfusions and transfusion for transfused trough a standard sterile blood
transfusion-dependent anemia should normally administration set containing an integrated
be carried out during the day. filter.(170µm- 200µm).
INFUSION RATES
Initial flow rate 1ml/min and if there is no - To minimize clogging of the filter, a
reaction at 15 min increase the rate to maximum of 4 units of red cells should be
4ml/min. transfused trough a giving set.
Except in the massive transfusion setting,
transfusion rates for blood should not exceed - In an emergency bleeding situation 8-10
units of red cells may be transfused before
2-4 ml/kg/hr. the giving set is changed.
Platelets and plasma flow rate is 10ml/min.
DEVISES USED FOR TRANSFUSION - Each administration set should be used
CANNULA within 8 hours to prevent the risk of
There is no minimum or maximum size bacterial contamination.
cannula for transfusion.
The size of the cannula chosen should depend - Platelets must not be transfused through a
giving set which has been used to transfuse
on the size of the vein and the speed at
red cells.Cellular debris in the filter will trap
which the blood is to be transfused. the platelets
General Transfusion Practices
BLOOD WARMERS
ELECTRONIC PUMPS
A specially designed commercial device with
a visible thermometer and audible warning is Electronics infusions pumps may be used for
to be used. the administration of red cells/plasma if they
have been verified as safe to use for this
Red blood cells expose to temperatures above purpose according to the manufacturer’s
400C may cause red cell haemolysis.
instructions.
Blood that has been warmed cannot be
returned back to TMD. COMPATIBLE INTRAVENOUS
SOLUTIONS
Clinical indications Administration sets may be primed with
- Large volumes transfused rapidly. 0.9% Normal Saline or the component being
e.g at flow rates > 50ml/kg/hr in adults transfused.
> 15ml/kg/hr in children Do not use Dextrose solutions (may induce
- Neonates requiring exchange haemolysis ).
transfusions. Do not use Lactated Ringers (may induce clot
- Transfusion for patients with clinically formation in the blood pack/or administration
cold reactive antibodies.(Cold set as it contains calcium).
agglutinins reacting at 370C in vitro.) Medications must not be added to
any blood components or transfusion line.
General Transfusion PracticesPLATELETS
TIME LIMIT FOR TRANSFUSION
RED CELLS Transfuse immediately as soon as the platelets
are received from the TMD.
Transfusion should begin as soon as possible
following removal of the unit from the If not used immediately platelet must be
refrigerator. returned to blood bank within one hour of issue.
FFP
When a short delay occurs red cells may be Must be transfused immediately after thawing.
held at room temperature for less than 30 Return to blood bank within 30 minutes if not
minutes prior to transfusion. transfused.
Thawed FFP can be stored at 2-6oC for 24 hours
If transfusion cannot be started within 30 until use.
minutes the unit should be returned without a
CRYOPRECIPITATE
delay to the blood bank.
Must be transfused immediately after thawing.
If the unit is not used it must be returned to
If a unit has been out of controlled storage for
the blood bank immediately where it can be
>30 minutes the unit cannot be accepted
stored at room temperature for up to 4 hours
back into the blood bank stock.
until used.
Transfusion
reaction
Blood products
Transfusion Risk
Risk factors
Multiple transfusion / multiparous
Emergency uncrossmatched blood
Individual patient characteristics Immunocompromised
Cardiovascular disease
Types and volume
Blood product Leucodepleted products
Storage & time of delivery
Leucocyte-filter
Equipments Infusion pump -> mechanical damage
Blood warmer
IV medications or other fluids through
Concomitant medications and the same tubing -> interfere with
intravenous fluids anticoagulant effect of citrate except 0.9%
normal saline.
Indications
Procedures Clear documentation
Well-trained staff
Acute Non-immunologic
Acute Immunologic Transfusion associated sepsis
Acute Haemolysis Reaction Hypotension associated ACE inhibition
FNHTR TACO
Non-immune haemolysis
AAR
Air embolus
Anaphylactic reaction Hypocalcaemia
TRALI Hypothermia
Classificatio
n
Delayed Immunologic
Alloimmunization Delayed Non-
Delayed hemolytic reactions immunologic
GVHD Iron Overload
Post-transfusion purpura
Types of Non-
Immunological Incidence Incidence
Reaction Immunological
Acute haemolytic Variable (1:12 000 –
transfusion reaction 1:177000 : ABO Hypothermia Variable
incompatibilty)
Allergy reactions 1-3% plasma Metabolic
Variable
transfusion complications
1:20,000 – Platelet (1:7500)
Anaphylaxis Bacterial
1:50,000 Red cells (1:
contamination
Immediate 500,000)
Transfusion
Febrile non-haemolytic associatied
1:100 – 1: 1000 1%
reaction Circulatory
Overload (TACO)
Transfusion Related
1:50,000 – 1: Non-immune
Acute Lung Injury Variable
190,00 haemolysis
(TRALI)
Transfusion-
Alloimmunisation Unknown Variable
transmitted disease
Delayed haemolytic
1:2500 – 1:11000 Iron overload Unknown
transfusion reaction
Delayed Post-transfusion purpura
Rare
(PTP)
Transfusion-associated
Graft-versus-host- Rare
disease (TA-GVHD)
Acute haemolytic
•
transfusion reaction
When to suspect?
• Fever, tachycardia
• Chills, rigors, dyspnoea, chest and/or flank pain, discomfort at
infusion site, abnormal bleeding or shock
• Oliguria, haemoglobinuria
• Anaesthetised patients
• BP, DIC
• What is the cause?
• Immunologic destruction of donor red cell
• Most common ABO incompatibility
• How to assess?
• Clinical assessment
• Check clerical records
• Laboratory investigations
• FBC / LFT / RP
• Direct Antigent Test / Indirect Antigen Test
• Test for haemolysis :
• Haptoglobulin, Urine Haemoglobinuria
• Report incident and return blood to blood bank
• What should be done?
• Stop transfusion
• Alert Transfusion Service Provider
• Maintain blood pressure and renal output
• Maintain airways
Allergic Reaction
• When to suspect?
• Urticaria, rash, pruritis
• Flushing, wheezing, hypotension, angioedema
• What is the cause?
• Hypersensitivity to allergen or plasma protein
• 1-3% plasma transfusion
• What to do?
• Stop transfusion
• Mild : anti-histamine
• Severe :
• Adrenaline
• Corticosteroids
• ABC resuscitation
• Consider pre-medications / washed pack cells in
next transfusion
Anaphylaxis
• When to suspect this adverse reaction?
• Sudden onset of cough, bronchospasm,
laryngospasm, respiratory distress, vascular
instability, nausea, abdominal cramps, vomiting,
diarrhoea, shock and loss of consciousness
• May be a fatal reaction.
• 1:20,000 to 1:50,000
• Usual causes?
• IgA-deficient patients who have anti-IgA antibodies
of the IgE class
• IgE-mediated allergy to other plasma proteins
• Rarely due to donor medication.
• Investigation?
• Recipient’s pretransfusion sample for IgA
deficiency
• Presence of anti-IgA antibodies.
• What to do?
• Stop transfusion immediately
• Maintain airway and intravenous line
• Administer adrenaline and corticosteroids
• Maintain BP
• Future use of autologous, washed or components
from IgA-deficient donors
Febrile non-haemolytic transfusion reaction
• When to suspect this adverse reaction?
• Temperature rise of ≥ 1 ºC from baseline during or shortly after transfusion, in the absence of
other pyrexic stimulus.
• Chills, rigors and headache
• Incidence: 0.1% to 1% in universal leucocyte depleted transfusion
• Usual causes?
• What to do?
• Stop transfusion immediately and follow other steps for managing suspected transfusion
reactions.
• Treat the fever with an antipyretic
• Consider and exclude other causes
• Rule out haemolysis, septic reaction and transfusion-related acute lung injury (TRALI).
Transfusion-related Acute Lung Injury (TRALI)
• When to suspect this adverse reaction?
• Onset of fever, chills, dyspnoea, tachypnoea, tachycardia, hypotension, hypoxia and noncardiogenic pulmonary
oedema during or within 6 hours of transfusion.
• Usual causes?
• The pathogenesis is not completely understood but theorised to be due to either human leucocyte antigen (HLA)
or human neutrophil antigen (HNA) antibodies found in the donor’s blood directed against the recipient’s
leucocyte antigen.
• This reaction activates neutrophils in the lung microcirculation, thereby releasing oxidases and proteases that
damage and make blood vessels leak.
• Investigation
• Test the donor or recipient serum for HLA or granulocyte antibody. Demonstration of these antibodies supports
diagnosis.
• Chest X-ray
• What to do?
• Stop transfusion immediately and follow other steps for managing suspected transfusion reactions.
• Provide cardiovascular and airway support. Administer supplemental oxygen and employ ventilation as necessary.
• Notify your Transfusion Service Provider to contact the Blood Service so we can quarantine and test related
components from the same donor.
• CXR
Bacterial infection
• When to suspect this adverse reaction?
• Usual causes?
• Investigation
• Clinical assesment
• Request for blood cultures from the patient, and perform culture and gram-
stain of the blood component.
• Keep the blood bag and giving set (sealed) for further investigation.
• What to do?
• Stop transfusion immediately and follow other steps for managing suspected
transfusion reactions.
• Seek urgent medical assistance.
• Start broad-spectrum antibiotics once cultures have been taken, including
cover for staphylococcal infections.
• Provide cardiovascular support.
Transfusion-acquired Graft-versus-host Disease
• When to suspect this adverse reaction?
• Fever, rash, liver function abnormalities and pancytopenia.
• Severely immunocompromised recipients
• immunologically normal recipients heterozygous for a tissue antigen
haplotype for which the donor is homozygous, especially directed
donations from family members.
• Usual cause?
• Viable T lymphocytes in the transfused component engraft in the
recipient and react against tissue antigens in the recipient.
• Investigation
• Skin biopsy
• Demonstrate donor leucocyte engraftment.
• What to do?
• Provide supportive care.
• Patients at risk
• Transplant patients
• Given purine analogue
• Immunologically impaired patients
• Hodgkin’s Lymphoma
• ? Alentuzumab
• Congenital immunodeficiency
• Exchange transfusion
• Low birthweight neonates
SYMPTOMS REPORTED
CHILLS AND RIGORS 77
FEVER 31
URTICARIA 50
HYPOTENSION 9
TACHYCARDIA 18
DYSPNOEA 15
VOMITTING 4
OTHERS 7
mmon adverse reaction and guide to clinical action
Signs & symptoms Possible diagnosis Investigation Clinical actions
Stop transfusion
Bacterial
Blood and bag culture Provide supportive care
Fever >1 oC over baseline or >38 contamination
Give IV antibiotics
Chills, rigors
Febrile non-
Exclude other causes Give antipyretics
haemolytic
Slow transfusion
Allergy Nil
Give antihistamine
Rash, hives, wheeze, dyspnoea, ABC resuscitation
hypotension Give adrenaline and steroid
Patient IgA level
Anaphylaxis Consider IgA-deficient or washed
Anti-IgA antibodies
components(particularly red cells) in
future
Check ABO
ABO incompatibility Stop transfusion
Type DAT IAT
Chills, hypotension, back pain Resuscitate
RP, Coag, Hb Maintain BP and renal function
Haemoglobinuria Haemolysis
Haemolysis tests
Ooze from IV sites
Bacterial Blood and bag
Give IV antibiotics if sepsis possible
contamination cultures
Slow or stop transfusion
Dyspnoea, productive cough Circulatory Overload Clinical Give oxygen, diuretics
Pink frothy sputum Position your patient upright
Pulmonary oedema TRALI occurs within Stop transfusion
Hypotension with TRALI HLA granulocyte
6 hours of Provide supportive care
antibody test
transfusion Notify Blood service provider
Conclusion
• Transfusion should be taken seriously
• Well indicated, counseled
• Carried out safely
• Any reaction during and within 6 hours of blood
transfusion should be regarded as transfusion reaction
• Attend immediately
• Emergency
• Investigated / Reported
Differential Diagnosis AHTR – one of the Top 3 causing transfusion related
1. AHTR fatalities
- Antigen-positive red cells are transfused to a recipient who has
2.FNHTR incompatible alloantibodies intravascular hemolysis
- Etiology – ABO incompatibility, Alloantibodies, Others
3. Bacterial Sepsis
- Signs/Symptoms (within 15 min, 20-30ml) & Investigations
4. TRALI - Management – Stop, Monitor, Report
* DDx of
PATIENT develops shortness of breath and hypoxia while
receiving unit of Packed RBC.
Differential Diagnosis TRALI – Definition
1. Duration – during or within 6 hrs of transfusion
1. TRALI 2. Acute Lung Injury (1. Acute onset 2. Hypoxemia 3.
2. TACO Bilateral infiltrates on CXR 4. No evidence of circulatory
3. TAD overload)
4. Anaphylaxis 3. No pre-existing ALI or other reasons for ALI
5. AHTR Mechanism – 1. Immune Passive transfer of donor
6. Bacterial Sepsis alloantibodies 2. non-immune infusion of biologic
7. Unrelated response modifiers (cytokines, CD40 L, Lipids with
Neutrophil-priming activity)
Rx – Stop, Ventilatory Support
Prognosis – 80% improve within 48-96 hours
Mortality – 5-10% of cases
TACO –
Risk factors – 1. Age 2. Flow rate 3. Volume 4.
Underlying
Rx – Stop, upright position, O2, Diuretics, Support
Timing Symptoms Signs Cause Management
• TPPA (Syphilis)
• HBsAg
• HCV EIA 3.0
• HIV EIA 1,2 + p24 Ag
• NAT-ID – HIV, HCV, HBV
How to prevent Transfusion
Reactions?