BLOOD

TRANSFUSION
BY : Dr. HIRA HANIF
TRANSFUSION TEN
COMMANDMENTS
1. Transfusion should only be used when the benefits outweigh
the risks and there are no appropriate alternatives.

2. Results of laboratory tests are not the sole deciding factor for
transfusion.

3. Transfusion decisions should be based on clinical assessment

underpinned by evidence-based clinical guidelines.

4. Not all anaemic patients need transfusion (there is no

universal ‘transfusion trigger’).

5. Discuss the risks, benefits and alternatives to transfusion with

the patient and gain their consent.
6. The reason for transfusion should be documented in the
patient’s clinical record.

7 .Timely provision of blood component support in major

haemorrhage can improve outcome – good
communication and team work are essential.

8. Failure to check patient identity can be fatal. In any

discrepancy, DO NOT TRANSFUSE.

9. The patient must be monitored during the transfusion.

10. Education and training underpin safe transfusion

practice.
BLOOD DONATION

1. The minimum age for donation is 17 years. There is no upper

age limit for regular donors,

2. The minimum body weight for blood donation is 50 kg (7st 12

lb)

3. The normal interval between whole blood donations is 16

weeks (minimum 12 weeks). The minimum pre-donation Hb
concentration is 12.5 g/dL for female donors and 13.5 g/dL for
males.
TESTS ON BLOOD DONATIONS
Screening for infectious agents

At each donation, the following mandatory tests are performed:

■ HBsAg
■ Human immunodeficiency virus – HIV
■ anti-HCV
■ Human T-cell lymphotropic virus
■ syphilis antibodies.
Some donations are tested for cytomegalovirus (CMV)
antibodies for patients with certain types of impaired immunity.
Additional test
■ Malarial antibodies
■ West Nile Virus antibodies
■ Trypanosoma cruzi antibodies.
SAFE TRANSFUSION –
RIGHT BLOOD,
RIGHT PATIENT,
RIGHT TIME
AND
RIGHT PLACE
ESSENTIALS

■ Is blood transfusion necessary in this patient?

■ If so, ensure:
• right blood
• right patient
• right time
• right place.
DOCUMENTATION

Pre-transfusion:
■ mention the reason for transfusion, the components to be
transfused and their dose/volume and rate

Informed Consent
• A single informed consent may cover many transfusions if they
are part of a single course of treatment.
During transfusion:
■Details of staff members starting the transfusion.
■Date and time transfusion started and completed.
■Donation number of the blood component.
■Record of observations made before, during and after transfusion.

Post-transfusion:
■Management and outcome of any transfusion reactions or other
adverse events.
 Initiating the Transfusion
 Immediately before transfusion, mix the unit of blood
thoroughly by gentle inversion.
 Flow Rates

 Initial Flow Rate Slowly at no more 1 mL/minute to allow for

recognition of an acute adverse reaction.
 Standard Flow Rate - If no reaction occurs in the first 15
minutes, the rate may be increased to 4 mL/minute
Maximum Infusion Time Infusion time should not exceed 4
hours for any component.
 If rate slows appreciably investigate immediately

Consider measures that may enhance blood flow

• repositioning the patient's arm,
• changing to a larger gauge needle,
• changing the filter and tubing,
• and elevating the IV pole, if gravity rather than a pump is being
used.
DURING THE TRANSFUSION MONITOR AND DOCUMENT

What •Temperature, blood pressure, respirations and pulse, and

examine the skin for urticaria.
When • before initiating the transfusion
• After the first 15 minutes
• After 30 minutes
• Hourly until one hour after completion of the transfusion
 Inpatients should be observed for late reactions over the next 24
hours and day-care patients advised to report symptoms developing
after discharge.
 In severe haemolytic transfusion reaction,sign and symptoms may
appear within minutes of infusing only 5-10ml of blood.close
observation at the start of the infusion of each unit is essential.
BLOOD AND BLOOD
PRODUCTS
WHOLE BLOOD

• One unit of whole blood contains –

1. 450 ml of donor blood.
2. 50 ml OF ANTICOAGULANT-PRESERVATIVE SOLUTION.
3. HAEMOGLOBIN approx. 12g/ml & HAEMATOCRIT 35% - 45%.
• No functional platelets.
• Stored between +2 and +6 degrees centigrate in a blood bank
refrigerator.
WHOLE BLOOD
Indications –
 red cell replacement in acute blood loss with hypovolaemia

 Exchange transfusion

contraindications –
 chronic anaemia

 incipient cardiac failure

PACKED RED CELLS
•One unit of packed red cells is approx. 330 ml AND HAS A
HAEMATOCRIT OF 50-70%.
•Indicated in replacement of red cells in anaemic patients
and also used with crystalloid and colloid solutions in
acute blood loss conditions.
FRESH FROZEN PLASMA

 Fresh frozen plasma is rich in coagulation factors.

 It is the first line therapy in the treatment of
coagulopathic haemorrhage.
 Also used in the replacement of multiple coagulation
factor deficiencies like
 Liver disease,

 Warfarin overdose

 Depletion of coagulation factors in patients receiving

large volume transfusions
 Disseminated intravasular coagulation and

 Thrombotic thrombocytopenic purpura.

 Dosage – initial dose of 15ml/kg.
PLATELETS
 Platelets are supplied as a pooled platelet concentrate
containing about 250 x 10 9 cells per litre.
 Are usually given to patients with
 Thrombocytopenia or
 Those with platelet dysfunction who are bleeding or
undergoing surgery and
 In patients with bone marrow failure.
 Not indicated in – patients with
 ITP,
 TTP,
 Untreated DIC
 in cases of hypersplenism.
PLATELETS (CONT..)
•DOSAGE – 1 UNIT /10 kg BODY WEIGHT.
•4-6 donor units of platelet concentrates will raise
the platelet count by 20-40 x 109/l. Increment
will be less if there is associated septicemia, dic,
splenomegaly.
CRYOPRECIPITATE
•Cryoprecipitate is a supernatant precipitate of
fresh frozen plasma and is rich in factor viii and
fibrinogen.

•Indicated in low fibrinogen states

ADVERSE EFFECTS
OF TRANSFUSION
ESSENTIALS

■ Modern blood transfusion is very safe but preventable death and

major morbidity still occurs.

■ Inappropriate decisions to transfuse ,put patients at unnecessary

risk of transfusion errors, reactions and transfusion-transmitted
infection.

■ Identification errors (of patients, blood samples and blood

components) by hospital staff are the root cause of most ‘wrong
blood into patient’ incidents, including ABO incompatible
transfusions.
■ Severe acute transfusion reactions are the most common cause
of major morbidity. These include immunological reactions
(predominantly allergy/anaphylaxis, haemolytic reactions and lung
injury), circulatory overload and rare bacterial contamination of
blood components.

■ If a serious transfusion reaction is suspected – stop the

transfusion; assess clinically and start resuscitation if necessary;
check that the details on the patient’s ID band and the
compatibility label of the blood component match; call for medical
assistance; contact the transfusion laboratory.
ACUTE TRANSFUSION REACTION
CATEGORY 1: MILD REACTION

Sign: Immediate management:

 Localized cutaneous  Slow the transfusion
reactions:  Administer antihistamineIM
 -urticaria (e.g:chlorpheniramine
 -rash 0.1mg/kg)
 If no clinical improvement
Symptoms: within 30 minutes,treat as
category 2
 Pruritus(itching)
ACUTE TRANSFUSION REACTION
CATEGORY 2(MODERATELY SEVERE REACTION)

Signs: Symptoms:
 Flushing  Anxiety
 Urticaria  Pruritus
 Rigors  Palpitations
 Fever  Milddyspnea
 Restlessness  Headache
 Tachycardia
ACUTE TRANSFUSION REACTION(CONT)
CATIGORY2: IMMEDIATE MANAGEMENT
1. Stop transfusion
2. Notify the doctor responsible for the patient and
blood bank immediately.
3. Send blood unit with transfusion set and new blood
sample with appropriate request.
4. Administer antihistamine IM(e.g:chlorpheniramine
0.1mg/kg)antipyretic(e.g:paracetamol 10mg/kg)
5. Give IV corticosteroids and bronchodilators if there
are anaphylacoid features(bronchospasm,stridor).
6. Collect urine for next 24hours for evidence of
haemolysis.
7. If no improvement for next 15 minutes ,treat as
category 3.
ACUTE TRANSFUSION REACTION
CATEGORY 3: LIFE-THERATENING REACTIONS
Sign: Symptoms: Possible causes:
 Rigors  Acute intravascular
 Anxiety
 Fever  Chest pain haemolysis
 Restlessness Pain near  Bacterial contamination and
 Hypotention(fall of infusion site septic shock
>20% of systolic Respiratory  Fluid overload
B.P) distress/shortness
 Anaphylaxis
 Tachycardia(rise of of breath
>20%in heart rate) Loin/back pain  Transfusion-associated
 Haemoglobinuria Headache acute lung injury(TRALI)
 (red urine) dyspnea
 Unexplained
bleeding(DIC)
LIFE-THERATENING REACTIONS
IMMEDIATE MANAGEMENT(CATEGORY 3)
1. Stop the transfusion
2. Infuse normal saline(initially 20-30ml/kg)to maintain systolic B.P.
3. Maintain airway and give high flow oxygen by mask
4. Give adrenaline(as 1:1000 solution)0.01mg/kg IM
5. Give I V corticosteroids and bronchodilators if there are
anaphylactoid feactures(e.g:bronchospasm, stridor)
6. Give diuretics:e.g;frusemide 1mg/kg IV
7. Send blood unit with infusion set.fresh urine sample and new
blood samples to blood bank for investigations
8. Check a fresh urine specimen visually for sign of
haemoglobinuria.
9. Assess for bleeding from puncture sites or wounds.if there is
clinical or laboratory evidence of DIC,……….give
platelets(adult:5-6 units) and either cryoprecipitate(adult:12
units)or fresh frozen plasma(adult: 3 units)
LIFE-THERATENING REACTIONS
IMMEDIATE MANAGEMENT(CATEGORY 3)
10.Reassess if hypotensive:
 Give further saline 20-30ml/kg over 5 minutes.
 Give inotropic if available.
11.If urine output falling or laboratory evidence of acute
renal failure(rising K+,urea,creatinine):
 Maintain fluid balance accurately.
 Give further frusemide.
 Consider dopamine infusion,if available.
 Seek expert help:the patient may need renal dialysis.
12.If bacteramia is suspected(rigor,fever,collapse,no
evidence of a haemolytic reaction)start broad-
spectrum antibiotics IV.
•Conscious patients often become very unwell within the first few
minutes of transfusion, complaining of flushing, loin and
abdominal pain and ‘a feeling of impending doom’.

•Unconscious patient( anaesthetised or cannot communicate),

the first indication of a reaction may be tachycardia, hypotension
and bleeding into the skin or from needle wounds, emphasising
the importance of careful monitoring of vital signs.
 ALTERNATIVES AND
ADJUNCTS TO BLOOD
TRANSFUSION
Intravenous Solutions
o Only isotonic saline (0.9%) is recommended for use with
blood components.
o Other isotonic electrolyte solutions that have been approved
by the FDA for this purpose may be used.
o Other commonly used intravenous solutions will cause
varying degrees of difficulty when mixed with red cells. For
example, 5% dextrose in water will hemolyze red cells.
Intravenous solutions containing calcium, such as Lactated
Ringer's solution, can cause clots to form in blood.
o Prior to blood transfusion, completely flush incompatible
intravenous solutions and drugs from the blood administration set
with isotonic saline.
ANTIFIBRINOLYTIC AND PROCOAGULANT DRUGS

Tranexamic acid
Tranexamic acid, a synthetic lysine derivative, inhibits
fibrinolysis (the breakdown of blood clots) by reducing the
conversion of plasmin to plasminogen. It is low cost and can be
used by the oral or intravenous route.

Example:
Postpartum haemorrhage (WOMAN trial): 1 g IV followed by a
further 1g if bleeding continues or recurs.
 EFFECTIVE
TRANSFUSION IN
SURGERY AND
CRITICAL CARE
ESSENTIALS
1. In the haemodynamically stable, non-bleeding patient
transfusion should only be considered if the Hb is 8.0 g/dL or
less.

2. Most invasive surgical procedures can be carried out safely

with:
• a platelet count above 50X109/L or
• international normalised ratio (INR) below 2.0.

3.fresh frozen plasma (FFP)

The benefit of routinely transfusing fresh frozen plasma (FFP) in
a fixed ratio to red cells (‘shock packs’) in traumatic haemorrhage
is still uncertain

4. tranexamic acid
CRASH-2 trial has proven that early administration of tranexamic
acid reduces mortality.
Transfusion in surgery

Preoperative optimisation

■ Anaemia (and other relevant health problems) should be identified

and treated in a timely fashion before surgery.

■ Patients at increased risk of bleeding, especially those on

anticoagulants or antiplatelet drugs, should be recognised.

■ The use of blood conservation techniques in appropriate patients

should be planned in advance.
Minimising blood loss at surgery

■ Drugs that increase bleeding risk should be withdrawn if safe to

do so.
■ Blood-sparing surgical and anaesthetic techniques should be
used.
■ Antifibrinolytic drugs, tissue sealants and intraoperative cell
salvage procedures should be used when appropriate.

Avoiding unnecessary transfusion after surgery

■ Use restrictive ‘transfusion triggers’, balancing safety and

effectiveness in individual patients.
■ Minimise blood loss from blood tests.
■ Prescribe iron and other stimulants to red cell production as
needed.
COAGULATION AND MAJOR HAEMORRHAGE

•The transfusion of large volumes of red cells and other

intravenous fluids that contain no coagulation factors or platelets
causes dilutional coagulopathy.
• Major traumatic haemorrhage is often associated with
activation of the coagulation and fibrinolytic systems (‘acute
traumatic coagulopathy’).
• Plasma fibrinogen predictably falls to sub-haemostatic levels
(<1.5 g/L) after 1 to 1.5 blood volume replacement (earlier in the
presence of coagulopathy and hyperfibrinolysis).
COAGULATION AND MAJOR HAEMORRHAGE (CONT..)

 Coagulation is also impaired by

 hypothermia

 acidosis

 reduced ionised calcium (Ca2+) concentration

 EFFECTIVE
TRANSFUSION IN
OBSTETRIC PRACTICE
Essentials

1. Inappropriate transfusions during pregnancy and the

postpartum period expose the mother to the risk of
haemolytic disease of the fetus and newborn (HDFN) in
subsequent pregnancies.

2. Prevention and treatment of anaemia in pregnancy (most

commonly due to iron deficiency) avoids unnecessary blood
transfusion.

3. A blood count should be checked at the antenatal booking visit

and at 28 weeks (allowing sufficient time to treat iron
deficiency before delivery).
5. Oral iron replacement is appropriate for most patients, but
intravenous iron (after the first trimester) may produce a more
rapid response and should be used in women intolerant of oral
iron.

6. Transfusion is rarely required in haemodynamically stable

pregnant women with Hb >7.0 or 8.0 g/dL unless there is active (or
a high risk of) bleeding.

7. Cytomegalovirus (CMV) seronegative red cells should be

provided for elective transfusions in pregnancy but standard,
leucodepleted units may be used in an emergency to avoid delay.
THANK YOU