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DEPARTMENT OF TRANSFUSION MEDICINE

BLOOD TRANSFUSION PRACTICE FOR

RESIDENTS

JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION & RESEARCH

PUDUCHERRY – 605 006

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INDEX

1. Role of blood transfusion service of JIPMER

2. Blood donation and donor referral

3. Requisition for blood and components

4. Issue of blood and components

5. Administration of blood and components

6. Blood component therapy

7. Neonatal and childhood transfusion

8. Transfusion in special settings

9. Leuco-depleted and Irradiated Blood Components

10. Transfusion reactions

11. Stem cell Transplant and Therapeutic Plasmapheresis

12. Good Blood Management Practice

13. Maximum Surgical Blood Ordering Schedule

14. Biosafety

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1. Role of Blood Transfusion Service of JIPMER

The blood transfusion service is committed to provide the safe blood to

the patients of this hospital. The main role of the blood bank is to provide safe and

timely blood and blood components to the patients and provide accurate results of

the tests ordered by various departments which can happen with mutual

cooperation and coordination between departments.

The blood bank strives to ensure that there is an adequate inventory of all

blood types and blood components to meet the needs of the patients. The blood

bank does donor selection, blood collection, component preparation, screening for

transfusion – transmitted infections and blood processing. Serologically compatible

blood and components are provided to the patients after pre-transfusion testing as

per the standard protocol. In addition, serological investigations for autoimmune

disorders, hemolytic disease of newborn and transfusion reactions are carried out.

Single Donor Platelets, Therapeutic Leukapheresis and Therapeutic Plasma

Exchange procedures are also available in selected cases. Necessary infrastructure is

being developed to meet the requirement of special blood components such as

peripheral blood stem cell, irradiated components etc.

The blood bank is involved in training of Medical Laboratory Technicians,

Undergraduate Medical students and Residents of Transfusion Medicine and

Pathology.

This informative manual on blood transfusion is designed to disseminate

knowledge about safe blood transfusion practices to the Clinical Residents, Nursing

staff and other Medical Personnel involved in arranging blood or component

transfusion to the patients.

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“DONATE BLOOD & SAVE LIFE”

FLOW CHART OF FUNCTIONS OF BLOOD BANK

1.

Blood Donor

Selection

Reject Accept

Blood Donation

TTI Screening

Positive Negative

Discard Inventory

Patient

Sample

Red Cells Component

Pre transfusion Testing ABO Match

Compatible

Used Unused

Issue

Returned back to BC

Acceptable Unacceptable

DISCARD

Issue

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2. Blood donation and donor referral

All efforts are made to provide Blood and components by the transfusion services to

the patients irrespective of replacement donation.

For planned / elective surgeries, blood donation may be made well in advance, at

least 72 hours prior the surgery. The patient’s relatives should be instructed to

donate required quantity of blood.

Guidelines for referring the donor to Blood bank:

1. Timing of blood donation: 9.00 AM to 4.00 PM from Monday to Friday and 9.00

AM to 12.30 PM on Saturday. Blood donation is closed on Sundays and Gazetted

Holidays.

2. On certain days when voluntary blood donation camps are held (Expected

collection more than 100 units) most of blood bank bleeding section will be

deputed to camp, hence either bleeding at blood bank will be restricted or it may

be closed.

3. Only relatives and friends of the patients who voluntarily agree; and voluntary

donors will be accepted for blood donation. Paid donation is strictly prohibited

and punishable by the law.

4. Certain categories of donors called as Captive or Coerced donors, such as

servants working in a household, subordinates, donors having multiple sex

partners, jail inmates, drug abusers or long term medication ( except few) are not

safe donors and therefore should be discouraged.

5. Before referring the blood donor to the blood bank, ensure that the donor is in

good health, free from chronic ailments, not on medication and in the age group

of 18 to 60 years (Ideally 20-50 years). Minimum weight more than 45 Kgs

(Ideally-50 Kgs.) Donor will be bled only if found fit after thorough questionnaire,

required physical examination with investigations conducted at the blood bank.

Details of donor selection criteria can be obtained from the Blood bank.

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6. Donors can donate blood irrespective of their ABO/Rh groups. Blood group

specific compatible blood will be provided to the patients. In some cases Group

specific donations are required particularly in Rh Negatives, Bombay, A2, and A2B

etc.

7. When the donors are sent to blood bank for donation, they must be given a

requisition slip containing the name of the patient, hospital number,

Unit/Ward/OPD for whom the donation is to be made and the number of units

to be collected.

8. After blood donation, blood donation slip will be given indicating donation

number which should be retained, in the patient file.

9. This blood donation number is “NON-TRANSFERABLE”.

Referral of Plateletpheresis donors:

1. Single donor apheresis platelets (SDP) are prepared by the use of Cell Separators.

2. While every effort will be made to arrange voluntary donors for plateletpheresis,

however, primary responsibility for arranging suitable donors rests with the

Relatives / Consultant in charge of the case.

3. Timing for Apheresis: Donors should be sent before 10.30 AM for evaluation or

screening with the special request after informing the Blood bank. Apheresis

screening or procedure will not be performed routinely on Sundays and Gazetted

Holidays. If found fit then donor should come on any working day with prior

information (in case of camps it may not be possible) before 11am within 15

days.

4. In case of adverse donor reactions or problem with kit or equipment the

apheresis procedure may have to be abandoned and component may have to be

discarded.

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Plateletpheresis Donor Screening

Plateletpheresis donors should be ABO and Rh matched and they are pre-

screened for transfusion transmitted infections before the procedure

When donors are referred to the blood bank for evaluation, they should bring a

request containing the name, hospital number, diagnosis, blood group and

platelet count of the patient.

The Resident in charge of Apheresis will draw the blood sample from the donors

for ABO, Rh and TTI screening.

ABO and Rh matched and TTI screened plateletpheresis donors will be kept

reserved for the procedure. Repeat TTI screening is required if the duration

between screening and apheresis procedure is more than 15 days.

It will be the responsibility of clinical service resident to ensure that selected

donors are available at the time of the procedure.

Donor should avoid oily food before the procedure on that day.

Donors apart being fit for whole blood donation should not be on medication

with aspirin, Anti platelet aggregating medication and should have Platelet

counts more than 1.5lakh/cumm with normal complete blood count.

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3. Requisition for blood and components

1. All blood requisition must have following information, without which requisition

will not be accepted.

Name of the patient & Father’s or Husband’s Name

Hospital Number

Location of patient( ward/ bed/OPD Unit )

Gender

Age

Haemoglobin, other hematological parameters as required for different blood

components.

Name of the Consultant & Signature of Resident In Charge with date

Mobile number of Resident and PABX number of ward. (IMPORTANT)

In case of previous transfusions feedback form with Blood group & Rh type is

mandatory.

2. Check the appropriate box to indicate what type of component and number of

units to be cross-matched.

3. MSBOS given below may be referred for number of blood units required.

4. Provide relevant clinical details, such as diagnosis, indication for transfusion, past

history of transfusion or reactions, any medications, history of hemolytic disease

etc.

5. Check the appropriate box to indicate the priority of the transfusion

requirement.

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ROUTINE: Blood or component is not required for at least 8 hrs. from the requisition

is received. In this type, every unit of blood is tested for irregular antibodies with

Coomb’s test etc. by standard techniques.

URGENT: Blood or component is not required for at least 1 hour from the time

requisition is received. In this type, only Immediate Spin cross match is done which

does not rule out irregular warm antibodies.

IMMEDIATE: Blood is required in less than 30 minutes from the time sample is

received. In this type no cross matching is performed, only ABO and Rh matched

blood is provided. Therefore, this option should be used with utmost care, as the

ordering physician will be responsible for the adverse effects. This option is rarely

required.

6. The person who draws the sample must affix his/her signature in the label on the

sample. Initials are not acceptable. The person signing is attesting that the

sample has been drawn from the patient by him / her.

7. Although, every blood sample is potentially infectious, special precautions are

taken for HIV, HBsAg, or HCV positive samples. Please indicate in bold letters or

use the sticker “BIO-HAZARD” on the top of the requisition form and sample so

that persons handling the specimen can take additional precautions.

8. Send the request form along with blood sample by ward attendant for cross

matching. Requisitions sent along with relatives or a friend of the patients is not

considered a good laboratory practice and will not be accepted.

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Guidelines for samples for blood and components:

SAMPLE FOR CROSS MATCH (For Red Cell transfusion only)

2ml EDTA & 5 ml clotted blood sample is required for cross-match of a unit of red

cells in adults. Additional sample is required at 1 ml / additional unit. (e. g. for cross-

match of 6 units of blood 10 ml of sample is required.

Justification for samples is:

i) Forward grouping will be done with EDTA & Reverse grouping and cross

matching with plain sample. It may decrease chances of wrong blood in tube

incidents.

ii) We have to keep pretransfusion samples for 7 days for any transfusion

reaction workup, in that we have to do DCT both on pre transfusion and post

transfusion samples.

SAMPLE FOR BLOOD GROUP ONLY

2 ml EDTA blood sample is required for ABO grouping and Rh typing.

The sample must be received in the blood bank by 12 noon one day before to ensure

availability of blood for routine transfusions. For urgent transfusions, sample must

reach Blood bank at least 2 hour before transfusion. In case of immediate transfusion

of uncross matched blood, sample must reach Blood bank 30 min before transfusion.

SAMPLE FOR FFP, CRYO OR PLATELET TRANSFUSION

For repeat transfusions of these components, there is no need for any blood sample,

provided the blood bank has record of the blood group of the patient or same may

be recorded at ward mentioning previous issue number with date.. For fresh / first

time transfusions, 2 ml EDTA and 3 ml Clotted sample will be required to determine

the blood group.

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SAMPLE FOR TRANSFUSION IN NEONATES

Serum of the newborn will have ABO antibodies of mother’s origin passively

transferred across the placenta. Therefore, cross matching will be performed using

mother’s sample for neonate till the age of 6 months and blood compatible with

both neonates and mother will be issued. 5 ml of clotted sample from mother and 2

ml EDTA sample from the new born will be required

1. Information required on the sample.

Name of the patient & Father’s or husband’s Name. It should match with the

name on the requisition form.

Hospital number of the patient matching with that on the requisition form.

Name of the test to be performed ( Grouping, cross matching)

Signature of the resident.

Date of collection of sample.

2. Samples from new born should be labeled as “Baby of mother’s name with

husband’s name” and should be labeled with mother’s identification, incase case

sheet is not made for the baby. All labelling should be done at one place not

around the bulb.

Labeling errors

Labeling errors are potentially life threatening and may result in transfusion of

incompatible blood/components.

Significant labeling errors include the following:

Overwriting

Correction not authenticated by signature.

Wrong or no Hospital No on specimen or requisition

Specimen drawn from the wrong patient, this can be avoided by withdrawing

sample into pre labeled tube at the bed side, one sample at a time.

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Name and / or Hospital number on the specimen not matching with name and /

or Hospital number on requisition.

Note: The specimen and requisition will be discarded by the blood bank if these

types of labeling errors are found. The Resident and / or Nurse will be informed

that a new specimen is required.

3. Minor labeling errors include the following:

Small spelling errors in name

No signature of the resident on the requisition.

In such cases, information will be conveyed by phone and unless the concerned

resident corrects the error, the specimen and requisition will be rejected and

fresh sample will be required.

4. Requisition for Fresh Frozen Plasma

Fresh frozen plasma is issued ABO group specific only. There is no need for cross

match.

The blood bank must have a record of the blood group of the patient on HIS. If

the record is not available as in case of fresh admission, a specimen for ABO

grouping must be sent along with the requisition.

The components are issued in 1 hour or less after the receiving requisition.

FFP thawed for more than 4 hrs. is deficient in labile coagulation factors.

Therefore, this product should not be asked in advance and store in refrigerator

in the ward.

Further details regarding contents, dose and indications for FFP can be found in

Section 5.

NEVER REFREEZE FFP

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5. Requisition for Cryoprecipitate

Cryoprecipitate is issued irrespective of ABO & Rh of the recipient

Rest all procedures and storage are similar to FFP

6. Requisition for Platelet Concentrate

The blood bank must have a record of ABO group on the HIS before platelets can

be issued.

ABO and Rh matched Platelets are issued as far as possible subject to availability.

There is no need of blood specimen provided the record of group is already done

and available on the HIS.

Platelets are not always available in stock and therefore additional time may

be required for preparation, TTI screening etc.

Since platelets need to be kept on agitator and wards do not have proper storage

for platelets they should not be ordered in advance. Send the requisition 30

minutes before transfusion is planned.

NEVER KEEP PLATELETS IN REFRIGERATOR

Further details regarding contents, dose and indications for platelet transfusion

can be found in Section 5.

Guidelines for requisition of blood and components in special circumstances

1. Non Group Specific transfusion:

While every effort is made to cross match ABO group specific blood to the

patient, non-ABO group specific blood or component may be issued in cases of

emergency due to blood shortages. Contact the blood bank in case any

clarification is needed.

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Compatible blood groups in case of non-ABO group specific transfusion

Patient Group Permissible donor groups for red cells

Permissible donor groups for FFP

O O O, A, B AB

A A, O A, AB

B B, O B, AB

AB AB, A, B O AB

Rh negative Rh negative Rh positive/Rh negative

Rh positive Rh positive, Rh negative Rh positive/Rh negative

2. Issue of Rh positive blood to Rh negative patients and vice versa

The incidence of Rh negative in our blood donors is 6.5%. It is therefore not

uncommon to face shortages of Rh negative blood. Rh positive blood can therefore

be given to Rh negative patients in life saving emergencies only certified by the

treating physician in consultation with officer in charge of the Blood bank. Rh

negative blood can be given to Rh positive patients without much reservation.

ABO

O

B

AB O A

RED CELLS

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Rh Type

VERY RARE INSTANCES

PLASMA

Safe compatibility choices when ABO and Rh Type identical Blood components are not available.

D NEGATIV

E

D POSITIVE

D POSITIVE

D NEGATIVE

O

B

O A A

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4. Issue of blood and components

1. In case of routine cross matches if ICT is negative blood units will be issued on

demand after doing immediate spin technique at Room temperature.

2. In case if Blood units are not lifted then they will be stored in the blood bank

refrigerator after cross match.

3. At present matched blood is collected from the Blood bank by interns/resident

doctors. Relatives or friends of the patients will not be allowed to collect blood

units from the blood bank.

4. Interns are required to bring proper details such as Patient name, Hospital

number, indication, diagnosis and type of blood components to be taken.

5. The blood bank personnel will enter the details of the blood units, including time

and date of issue. The intern/resident doctor will have to confirm details of blood

units in the issue register, compatibility form, cross match label and sign in the

register and write the name in capital letters before leaving. The intern will have

to cross check compatibility and certify, if necessary.

6. Return of unused blood

If the blood is not to be used for any reasons, return it to blood bank

immediately within 30 minutes.

Compatibility forms need to be sent to the Blood bank along with unused

blood.

The red cells units will not be accepted if one of the ports is opened. The

blood bag should have the labels attached to it which will help to proper

identification of units.

Note: Blood units should not be stored in the refrigerator in the ward. These

refrigerators are not specifically designated, monitored, tested and controlled, as

are blood bank fridges. Blood should be collected only 30 minutes in advance

before planned transfusion.

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5. Administration of blood and components

General Guidelines:

1. Check the blood or components before starting the transfusion. The following

must be checked.

Verify that you have received the required blood or component ordered.

Match ABO and Rh group of the patient with the ABO & Rh group of the blood

product label. If there is discrepancy, do not start transfusion. Report to the blood

bank and Residents in the ward immediately.

Check expiration date, unit number and component label.

Check the integrity of the unit by applying light pressure to the unit and examine

for any leaks.

Check the bag for presence of clots.

Compare the blood bag number with the number listed on compatibility report

Carefully observe the appearance of the unit.

2. Identification of the Patient:

This is a very important step before starting the transfusion, as misidentification of

the patient is the most common cause of mismatched transfusion and prove fatal

to the patient

Compare the patient name, Hospital number and blood group on the blood bag

with the patient name and Hospital number and blood group on the patient file.

If the patient is conscious, confirm the name by having him/her state the name

and compare it with the name on the compatibility report.

Before starting the transfusion, record the time, temperature of the patient, pulse

rate and BP on the patient file. This will be helpful to monitor any changes in the

vitals during transfusion.

The red cells should not be kept outside if transfusion is delayed. They should be

stored at 2 to 4 C.

RED CELLS SHOULD NOT BE STORED IN THE FREEZER COMPARTMENT

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Administration of red blood cell components:

1. Ensure the IV line is patent and Gauge of the needle is adequate to transfuse the

blood component. Use a standard blood transfusion set with filter issued by the

blood bank.

2. Examine the red cell bag for clots, abnormal dark purple blue color. Red cells will

usually be dark red in color. If anything seems abnormal, check with the blood

bank.

3. Invert the bag several times to ensure re-suspension of red cells. Follow the

administration instructions on the blood bag label.

4. Concurrent fluids along with red cell transfusion:

Avoid additions of any type of fluid or drug in to the blood bag.

Only compatible IV solution compatible with blood is isotonic (0.9%) saline and

may be used along with red cell transfusion.

Do not mix any medication along with red cell unit. Some drugs can cause

hemolysis due to their high pH. 5% dextrose can cause agglutination of red blood

cells. Ringer lactate solution can result in clotting because of its calcium content.

If medication were added to the blood component it would be difficult to

investigate the cause of the transfusion reaction if there is any.

Do not mix blood components together, e.g. red cells and platelets before

transfusion.

5. Start the transfusion slowly for first 15 minutes and observe the patient. If the

clinical status is OK, remaining unit can be transfused as per the indication.

However, check the patient frequently for any significant change in the vitals.

Record all vital signs on the case file and compatibility form.

6. Change the transfusion set after 4 units of blood.

7. Red Cell transfusion should be completed within 4 hours of starting. Beyond 4

hours, there is a risk of bacterial contamination.

8. If the transfusion is uneventful, return one copy of the compatibility form duly

filled to the blood bank and paste one in the case file.

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9. If there is any adverse reaction to the transfusions, see “Section 5” for action to

be initiated.

Note: If the blood product is not to be used for any reason, do not store in the

refrigerator in the ward as these refrigerators are not designated for blood

storage. Return unused blood bags to the blood bank immediately.

10. Discard the empty blood component bag in the Biohazard Waste Container in

the Ward, unless the patient has suffered an adverse reaction in that case the

bag has to be returned to the blood bank along with the completely filled

reaction form with filled in reaction form for investigation.

Administration of Plasma & Cryoprecipitate:

Follow the general guidelines of identification and inspection of blood

components as mentioned in red cell administration.

Thawed FFP will be clear with yellow straw color. Cryoprecipitate will usually be

cloudy.

Get FFP thawed in the blood bank.

Thawing of plasma components:

Thawing of FFP and Cryo is done at 37 C water bath.

Place the unit in a plastic over wrap so that water in the bath will not

contaminate the component.

The ports of the component bag should not come in contact with the water.

Squeeze the component intermittently to ensure rapid thawing.

Generally, thawing of FFP takes 10 to 15 minutes.

Note: Once thawed, plasma components should not be frozen. They can be

kept at 4 C for not more than 4 hrs.

A standard blood administration set is satisfactory for transfusion of plasma

components.

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Cryoprecipitate:

Cryo can be administered using a 50 ml syringe. After thawing, aspirate all Cryo

in a syringe with needle. A significant amount of Cryo will remain attached to the

walls of the plastic containers. Injecting 25 ml of isotonic saline in the bag and

rinsing it thoroughly can rectify this.

Follow rest of the procedure as mentioned in Red Cell administration.

Thawed cryoprecipitate should be stored at 4 C and used within 4 hours.

Administration of Platelet Products

1. General guidelines for patient identification and component inspection are same

as red cell administration.

2. A blood administration set issued by the blood bank should be used for platelet

transfusion. After platelets are transfused, it is preferred to rinse entrapped

platelets from the filter by flowing 50 ml of isotonic saline through it.

Platelet concentrates should not be transfused through the set used for

transfusing other blood components.

3. Transfusion of one unit of random unit of platelets should be completed in 20

minutes due to the risk of bacterial contamination.

4. Since platelets need to be stored on agitator, request and collect platelets from

blood bank just before transfusion.

5. Rest of the procedure is same as for red cell administration.

Note: Platelet products must “NOT” be refrigerated at any state.

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Use of Filters for administration of blood and components:

1. Routine blood transfusion sets have a filter with 170µ pore size.

2. Micro-aggregate filters: Micro-aggregate filters have a pore size of 40 micron.

They allow rapid transfusion of blood and components at the same time prevent

micro-aggregate from entering the circulation. They are used in cardio

pulmonary bypass surgery.

3. Leukocyte filters:

Leukocyte filters are used to prevent febrile transfusion reactions and CMV

transmission. They are especially useful in multiply transfused patients. Two

units of red cells can be transfused using a single filter. The proper selection of

the leukocyte filter should be made, depending on the type of component to be

transfused.

Warming of blood Products:

1. Generally, there is no need to warm the unit of red cells before transfusion.

Keeping the blood unit at room temperature for 30 minutes will be enough in

most cases.

2. In special circumstances, such as patients with cold agglutinins in the serum, it

is important to pre warm the unit at 37 C before transfusion. Special blood

warmers may be used for this purpose. Blood should not be warmed in Dry

Incubator in the laboratory. It is important to keep the patient warm during

transfusion.

3. Always check for the presence of hemolysis while using a blood warmer.

There is no need to warm blood before transfusion except in massive transfusion.

(Infusion rate @ 15 ml/Kg body weight/hour in children or @ 50 ml/Kg body

weight/hour in adults.)

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Hemoglobinuria may be due to following causes also: Transfusion of hemolysed donor red cells due to any cause will result in

hemoglobinuria

Bacterial contamination;

Excessive warming;

Erroneous freezing;

Addition of drugs or intravenous fluids;

Trauma from extracorporeal devices

Red cell enzyme deficiency.

Blood Transfusion in Autoimmune haemolytic anaemia may exacerbate the

hemolysis and be associated with hemoglobinuria.

Storage and shelf life of components:

Component Storage Temp Shelf life Compatibility

Packed Red Cells 2 to 6 C 35/42

days ABO, Rh, Cross-match

Fresh Frozen Plasma -30 C or

below

1 year ABO

Cryo-deficient Plasma -30 C or

below

5 years ABO

Platelet Concentrate 22 to 24 C 5 days Preferably ABO, but can be

given without regard to ABO

Cryoprecipitate -30 C or

below

1 year Any Group

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Time Limits for Infusion of Blood/Blood components:

TIME LIMITS FOR INFUSION

Component Start infusion Complete infusion

Whole blood or red cells

Within 30 minutes of

removing pack from

refrigerator

Within 4 hours or less in

high environmental

temperature

Platelet concentrates Immediately Within 20 minutes

Fresh frozen plasma and

cryoprecipitate

As soon as possible

Within 20 minutes

Factors will be lost, if

delayed

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BLOOD / BLOOD COMPONENT STORAGE & TRANSFUSION CRITERIA

COMPONENT STORAGE

TEMPERATURE TIME LIMIT DOSAGE REMARKS

RED CELLS / WB

+2 to 6 C in blood bank refrigerator

Start within 30 minutes of collection

Complete within 4 hours

1 unit increases Hct 3%

Hb 1gm% (Approx)

Must be ABO & Rh compatible

Xmatch required

RANDOM DONOR

PLATELETS (RDP)

+22 to 24 C

Under constant agitation

Start immediately

Complete each pack within 20

minutes

1 unit RDP increases 5000-7000 µl in stable

adults

ABO group specific preferable

Non group specific may be given

SINGLE DONOR PLATELETS (SDP)

+22 to 24 C

Under constant agitation

Start immediately

Complete within 2 hours

Increases platelet count by

30-60,000

ABO & Rh compatible

No Xmatch required

FRESH FROZEN PLASMA (FFP)

Minus 30 C

or below

Start as soon as possible

Complete within 4 hours

Factors will be lost, if delayed

10-15 ml / kg increases factor levels by 20-30%

ABO compatible

No Rh compatibility

No Xmatch required

CRYOPRECPITATE Minus 30 C

or below

Start as soon as possible

Factors will be lost, if delayed

1 unit / 10 kg

( FVIII = 100 I.U)

Any ABO & Rh group

No Xmatch required

If Products collected are not used they must be returned to the blood bank refrigerator within 30 minutes. Only solution compatible with blood is normal saline. Do not mix drugs with blood. Return compatibility form duly filled, after completion of Transfusion. Always use Blood administration set with filter issued by Blood bank All adverse incidents are investigated & reported to Blood bank.

NEVER FREEZE BLOOD / BLOOD COMPONENTS

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Blood Components and Plasma Products

Fresh Plasma

Whole blood Plasmapheresis

Fresh Frozen Plasma

Cryoprecipitate Cryosupernatant

Factor VIII Concentrate

Albumin

Immunoglobulin

s Other Concentrates

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6. Blood component therapy

The goal of transfusion therapy is to correct an abnormality that will not respond to

other modes of treatment and to provide a patient with life support when safer

alternatives are not possible.

Various Component that are available in the Blood bank for clinical use

Oxygen carrying components

o Red cell components

Platelet Products:

o Single donor platelet concentrates (Apheresis).

o Random donor platelet concentrate

Plasma Product.

o Fresh Frozen Plasma

o Cryoprecipitate

o Cryo poor plasma

Broad Indications for Blood Component Usage

Component YES NO

Red Blood

Cells

To increase oxygen- carrying

capacity in anemic patient

For volume expansion

To enhance wound healing

To improve general well being

Platelet

To control or prevent bleed

associated with documented

deficiencies in platelet number

and function

To treat ITP unless there is life-

threatening bleeding

TTP

Fresh

Frozen

Plasma

To increase level of clotting

factors in patients with

documented deficiency and who

are at risk of hemorrhage

For volume expansion

As a nutritional supplement

For prophylaxis during massive

blood transfusion

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Packed Red Cell Concentrate (PRBC)

Red Blood cells are the cellular product obtained after centrifugation of whole blood

and removal of most of the Plasma. The usual unit of PRBC should raise Hct or Hb by

approximately 3% or 1 gm% respectively in an average adult patient and 3 gm% Hb in

infants.

Indication of PRBC

There is no universal trigger for red cell transfusion. Clinical judgment plays vital role

in the decision to transfuse red cells or not. RBCs are the component of choice for

most patients with symptomatic deficit of oxygen carrying capacity.

Estimation of need based on haemoglobin concentration

Most patients with Hb of 6-7 gm/dl tolerate anemia well and need not be transfused

unless there are symptoms of anoxia. Patient with Hb >10gm/dl almost certainly

never require red cell transfusion. Therefore, in any given anemic patient, the aim of

transfusion therapy should be to correct the symptoms of the patient rather than

correcting the hemoglobin level.

Estimation of need based on Acute Blood Loss

15% loss of blood volume (750 ml in adult) No need of transfusion, if there is no

preexisting anaemia or cardiac or respiratory disease

15 -30% loss of blood volume (800 – 1500 ml in an adult) Need to transfuse

crystalloids or colloids. Need for red cell transfusion unlikely in the absence

preexisting disease

30 – 40% loss of blood volume (1500 – 2000 ml in an adult) Need rapid replacement

of volume with crystalloids or synthetic colloids and red cell transfusion will probably

required.

40% loss of blood volume (> 2000 ml in an adult) need rapid volumere placement

including red cell transfusion is required.

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Transfusion targets

Guide to number of units required to achieve the ‘target’ haemoglobin (Hb).

Amount of Hb in 1 unit of PRBC / Whole blood (350 ml unit)

Volume Average Hb Total Hb

350ml 13 g/dL 45.5 g/dL

Blood volume (70ml/Kg in adults)

Weight Blood volume Calculation Raise in Hb/unit transfused

43 Kgs. 3 Ltrs. 45.5*100/3000 1.52

57 Kgs. 4 Ltrs. 45.5*100/4000 1.14

71 Kgs. 5 Ltrs. 45.5*100/5000 0.91

Single unit transfusions in adults have previously been discouraged. However, the

above table shows that it might be reasonable to give one unit to elderly patients

with low body weight who is symptomatic.

Abuses of PRBC

Red cell transfusion should never be used as empirical transfusion for improving the

general wellbeing of the patient, for wound healing or for pre surgical transfusion.

Patients with nutritional anemia can be better treated with iron, folic acid or vitamin

B12 supplementation.

29

Platelet Concentrate (PC)

There are two types of PC available, random donor PC or single donor PC (apheresis-

PC)

1. Random Donor PC:

Each unit of PC is currently prepared from a unit of whole blood PC should be

stored at 22 C with continuous agitation for up to 5 days.

The number of PC to be administered depends on the clinical situation in each

patient, such as weight of patient, presence of DIC, sepsis, splenomegaly,

alloimmunization etc.

In adults therapeutic dose of random donor PC is 4 - 6 donor platelets.

2. Single donor PC (Apheresis PC)

This component is collected from an individual donor with the help of

apheresis machines (cell separators). . A single unit of apheresis PC contains 3-

5X1011 platelets / unit and is suspended in 200 ml of plasma. Therefore, one

unit of apheresis PC is equivalent to approximately 6 units of random donor

PC. It is especially useful for patients who are likely to receive long term

platelet support such as aplastic anemia or BMT recipients, leukemia etc, since

the number of donor exposures is decreased considerably. One unit of

apheresis PC raises the platelet count by 30,000 – 50,000/ul in adult patient.

Comparison of SDPs and RDPs

Characteristics SDP RDP

ABO + Rh matching Possible Inconsistent

Multiple donor exposure Less More

Chances of TTI Less More

No. of donors willing Less More

Cost High Low

30

Calculation of adequate dose:

Desired Plt rise X 109 / L X Blood Vol (L) Dose = ------------------------------------------------------ (splenic pool correction factor) 0.67

30x109 X 5 30 X 109 X 5 Dose = ------------------------------ = --------------------- = 4 – 5 RDP or 1 SDP (Correction factor) 0.67 0.67 X 0.5 X1010

(1 RDP ≈ 0.5 × 1010, 1 apheresis platelet ≈ 3.0 × 1011 platelets)

(1 X106 μL = 1 L. 30,000/ μL = 30x109 /L. Blood Vol = 5 L)

3. Assessment of response

The efficacy of each platelet transfusion should be checked by clinical

observation, by monitoring the platelet count increment (either at 24 hours or

at 1 hour) and, in some cases, by calculating the corrected platelet increment.

In a clinically stable patient, the expected increment after one therapeutic

dose of platelets is 30–40 x 109/L.

Corrected platelet count index (CCI)

The response to prophylactic platelet transfusions is often evaluated by

determining the corrected-count increment (CCI). This is performed by

measuring a platelet count 10 to 60 minutes post transfusion and then

calculating the CCI in adults/PPR in children according to the following

formulae:

Formulae used in the determination of platelet refractoriness [data from

(Rebulla, 1993)]

Platelet increment (PPI) = Post-transfusion platelet count – pre transfusion platelet count

31

PPI (L) x Body Surface Area (m2) CCI = ------------------------------------------------- = # Platelets transfused x 1011

PPI (L) x Blood volume (L) PPR = -------------------------------------------------- = # Platelets transfused X 1011

Percentage platelet increment = PPR / 0.67 (0.67 accounts for splenic pooling)

Model Calculations:

PPI=30,000/ μL = 30x109 /L

Estimate of platelet transfused = 3x1011

CCI = 30x109 /L x 1.5 m2 --------------------- = 0.15L = 15,000/ μL 3x1011

PPR= 30x109 /L x 5x100 ---------------------- = 50% 3x1011

Percentage platelet increment = 50 / 0.67 = 74.63

where Post is the post transfusion platelet count/μL drawn 1 hour after

completing the transfusion, Pre is the pre transfusion platelet count/μL, #

platelets is the number of platelets transfused (1 RDP ≈ 0.5 × 1010, 1 apheresis

platelet ≈ 3.0 × 1011 platelets), and BSA is body surface area in square meters.

Refractoriness is defined as a CCI <5000 after two sequential transfusions,

where at least one transfusion used fresh platelets (<48 hours old). Patients

with a low 1-hour post transfusion platelet increment may have become all

immunized to platelet transfusions.

32

Causes of refractoriness:

Immune

HLA alloantibodies

Platelet specific antibodies

Platelet autoantibodies

ABO incompatibility – rare

Nonimmune

Sepsis

Antibiotic/antifungal therapy

Disseminated intravascular coagulation

Splenomegaly

If non-immune platelet consumption appears likely, correct the clinical factors

responsible and platelet transfusions from random donors should be continued.

Indications:

PC are indicated for the prevention ( prophylactic) or treatment (therapeutic)

of bleeding in patients with decreased platelet count ( thrombocytopenia) or

defective platelet function or both.

1. Prophylactic transfusion

10,000 / μL without additional risk factors

2. Therapeutic transfusion

Standard for the treatment of thrombocytopenic bleeding

Haematological malignancies

Hypoproliferative states – aplastic anaemia

Massive transfusion

Acute DIC

Inherited or acquired platelet function disorder

Neonatal alloimune thrombocytopenia

33

Triggers for platelet transfusion in adults

Platelet threshold Clinical settings

< 100 X 109 /L Neurosurgery

CNS trauma

< 50 – 80 X 109 /L Epidural catheter insertion or removal

< 50 X 109 /L

Significant micro vascular bleeding

Lumbar puncture

Surgery

Vaginal surgery

< 20 X 109 /L Thrombocytopenia with fever or coagulapathy

< 10 X 109 /L Thrombocytopenia due to marrow failure

Platelet transfusions are not usually effective in patients of ITP.

In clinically stable patients with an intact vascular system and normal platelet

function, prophylactic platelet transfusions have traditionally been used when

the platelet count is less than 20,000/l.

Recent studies indicate that the threshold for prophylactic transfusion can be

set at 10,000/l in patients without fever or overt bleeding.

A patient undergoing surgery or other invasive procedures, in which

thrombocytopenia is unassociated with complicating factors is unlikely to

benefit from prophylactic transfusions if the platelet count is higher than

50,000/l.

Platelet transfusions may be indicated at higher platelet counts for patients

with systemic bleeding and for patients at a higher risk of bleeding because of

the presence of complicating factors such as sepsis, platelet dysfunction

related to medication or disease process.

34

Contraindications:

Patients with thrombotic thrombocytopenic purpura.

Patients with ITP unless there is life threatening bleeding or intracranial

hemorrhage.

Heparin induced thrombocytopenia

Adverse effects of platelet transfusion

febrile nonhaemolytic transfusion reaction(FNHTR)

allimmunization

bacterial sepsis

Unwarranted platelet transfusion generates alloimmunization reduing efficacy of

future transfusion, in addition to the usual adverse effects of blood component.

Fresh Frozen Plasma (FFP)

FFP is indicated in the control or prevention of bleeding in patients with multiple

coagulation factor defects. FFP must be thawed at 37 C in a water bath with due

precautions. FFP should be used as soon as it is thawed to avoid the decay of clotting

factors. Dose of FFP is 10 - 15ml/Kg body weight.

Indications for FFP

Each unit of transfused FFP will increase the level of any clotting factors by 2 to 3 %

in an average adult. Laboratory tests such as PT and APTT should be done to monitor

the FFP use in patients.

Broad spectrum coagulation factor deficiency.

severe liver disease

oral anticoagulant overdose

disseminated intravascular coagulation

massive transfusion with coagulation problems

Thrombotic thrombocytopenic purpura

AT III deficiency

35

Note: Most common abuses of FFP

1. Volume expansion

2. As protein supplements

3. Prolonged bleeding in the absence of coagulation defects.

Cryoprecipitate

Cryoprecipitate is the cold insoluble precipitate having Factor VIII, vWF, fibrinogen

and factor XIII as its major constituents. Standards require an average of 80 IU of

FVIII in each unit.

Dose: 1 Donor unit / 10 Kg patient’s body weight. Alternatively, number of cryo bags

required can be calculated substituting the value 80 IU / 1 cryo bag and formula

given below for Factor VIII concentrate.

Indications:

1. Factor VIII Deficiency (Hemophilia A): The treatment of choice is virus

inactivated factor VIII concentrates

2. Von Willebrand’s Disease

3. Hypofibrinogenemia (<80 mg/dl):

Consumptive coagulopathy ( DIC),

Dysfibrinogenemia or Afibrinogenemia.

4. Fibrin Glue for topical hemostasis.

5. Reversal of fibrinolytic therapy

6. Factor XIII deficiency

36

All pregnant women

All pregnant women

10-16 weeks

28 weeks

Delivery

If Anti-D is not detected at 28 weeks in RhD-negative mothers, routine antenatal prophylaxis given..

Action chart for blood grouping and antibody testing during pregnancy. Since most anti-K antibodies are stimulated by a previous transfusion, if the partner is proven to be K negative and there is certainty that he is the father of the child, regular antibody monitoring can be abandoned.

Test ABO + RhD blood groups

and antibody screen

Other Antibodies Anti-D Anti-c K-related antibodies

No antibodies

Test 4-Weekly

Recheck RhD group and

antibody screen*

Anti-D Anti-c K-related antibodies

Other IAT

reacting

antibodies

IAT

negative

antibodies

No antibodies

Test

fortnightly

Perform cord red cell DAT

MONITOR INFANT FOR HDN

Test cord red cell RhD group if mother is RhD negative

37

Post-delivery cord blood tests to be undertaken if

the mother has clinically significant antibody/ies

Direct antiglobalin test or DAT (positive if baby has corresponding antigen/s).

If the DAT is positive, test: o Haemoglobin o Bilirubin o Blood film (spherocytes are present if there is

significant haemolysis)

38

7. Neonatal and Childhood Transfusions

Pre transfusion testing for neonates and infants within the first four postnatal

months

Samples from both mother and infant should be obtained for ABO and Rh D typing.

Investigations on the maternal sample:

ABO and Rh D group

Screen for the presence of atypical red cell antibodies.

Investigations on the infant sample:

ABO and Rh D

ABO by cell group only (a reverse group would detect passive maternal

antibodies).

Direct antiglobulin test (DAT) performed on the neonate’s red cells.

In the absence of maternal serum, screen infant’s serum for atypical antibodies by an

indirect antiglobulin technique (IAT). A positive DAT on the neonate’s red cells or an

atypical red cell antibody in maternal or neonatal serum suggests possible

haemolytic disease of the newborn (HDN).

Selection of blood component

Components should be of the neonate’s own ABO and RhD group, or an alternative

compatible ABO and RhD group and compatible with any ABO or atypical red cell

antibody present in the maternal or neonatal plasma.

After the postnatal age of 4 months, compatibility tests should be conducted in

accordance

with pre transfusion testing in adult practice.

39

Choice of ABO Group for Blood Components for Administration to Children

Patients ABO Group Preferred ABO Blood Group of Components

Red Cells FFP Platelets

O

First choice O O O

Second choice - A or B or AB A or B

A

First choice A A A

Second choice O AB B

Third choice - O

B

First choice B B B

Second choice O AB A

Third choice O

AB

First choice AB AB AB

Second choice A or B A A or B

Third choice O - -

Group O fresh frozen plasma (FFP) should only be given to patients of group O. Although group

AB FFP can be given to people of any ABO blood group, supplies are usually limited.

Components which test negatively for 'high titre' anti-A and/or anti-B should be selected. The

use of group O platelets for non-O patients should be avoided as much as possible.

40

Suggested volumes and rates of neonatal transfusions:

These are general guidance and the actual values used will depend on the

clinical status of the baby at the time.

Component Volume usually administered Rate

Red cell concentrates

(1) Exchange transfusion

80-100 ml/kg (for anaemia) 160-200 ml/kg (for hyperbilirubinaemia)

Depends on stability of baby: discuss with NICU consultant

(2) Top-up transfusion

10-20 ml/kg* 5 ml/kg/h†

(3) Emergency large volume transfusion

10-20 ml/kg Rapid infusion only for resuscitation

Platelet concentrates

10-20 ml/kg 10-20 ml/kg/h

Fresh frozen plasma 10-20 ml/kg 10-20 ml/kg/h

Cryoprecipitate 5-10 ml/kg 10-20 ml/kg/h (i.e. over approx 30-60 min)

NICU - neonatal intensive care unit.

*May also use the formula:

Volume of packed cells (ml) = weight (kg) x desired rise in haemoglobin x 4.

† Furosemide is sometimes used, e.g. ventilation with acute respiratory distress.

Exchange Transfusion Exchanging the estimated volume of the baby’s blood in a ‘single-volume exchange’

will remove 75% of red cells, while a double-volume exchange (160–200 ml/kg,

depending on gestation) removes 90% of the initial red cells. A double-volume

exchange can remove 50% of available intravascular bilirubin.

Volume transfused is usually 80–160 ml/kg for a term infant and 100–200 ml/kg for a

preterm infant (i.e. 1–2 · blood volume) depending on the clinical indication.

41

SELECTION OF BLOOD FOR EXCHANGE TRANSFUSION IN Rh HDN

Blood selected should be should not be more than 5 days old.

Select blood collected into CPD anticoagulant. Avoid SAGM and other additive

solutions

If ABO group of the baby is the same as that of mother or compatible with

mother’s blood, Rh negative blood of same ABO group as that of baby is used

When baby’s ABO group is not compatible with mother’s ABO group , O Rh

Negative blood free of hemolysins anti A and Anti B is used

If exchange transfusion required more than once, subsequent blood should be

of same ABO and Rh type as that of first time

If no compatible blood is available, exchange transfusion with incompatible

blood is preferred to no transfusion at all. Baby`s ABO group may be used.

42

BLOOD GROUP RED CELLS

PLASMA

Baby’s

Group

Mother’s

Group I Choice II Choice

A

A A O

A, AB B O

AB A O

O O

B

A O

B, AB B B O

AB B O

O O

AB

A A O

AB B B O

AB AB A, B, O

O O

O

A O

O, A, B, AB B O

AB O

O O

43

ABO haemolytic disease of the newborn

Clinically significant haemolysis generally occurs only if the mother is group O

and the infant group A (occasionally in group B babies).

Group O blood, compatible with the maternal plasma, should be used for

transfusion (level If an ET is required in ABO HDN, this should be with group O red

cells with low titre plasma anti-A and anti-B, or with group O red cells suspended in

AB plasma.

Triggers for platelet transfusion in neonates

Infants < 4 months Administer platelets at

Preterm or term infant with bleeding < 50 X 109 /L

Sick preterm or term infant not bleeding

< 30 X 109 /L

Stable preterm or term infant < 20 X 109 /L

Platelet transfusion in neonates

Neonatal platelet count is same as in adults. The aim of platelet transfusion is to

keep count > 10 X 109 /L in children above 1 years . Dose is 5 -10 ml /kg group

specific or plasma compatible. Indications and contra indications are the same as

in adults. Triggers for neonates given in the table below.

Indications for prophylactic platelet transfusion in children Platelet count <10 · 109/l Platelet count <20 · 109/l and one or more of the following Severe mucositis Disseminated intravascular coagulation (DIC) Anticoagulant therapy Risk of bleeding due to a local tumour infiltration Platelet count 20–40 · 109/l and one or more of the following DIC in association with induction therapy for leukaemia Extreme hyperleucocytosis Prior to lumbar puncture or central venous line insertion

44

8. Transfusion In Special Settings

Massive transfusion is the loss of more than one blood volume within 24 hours.

1. The aim of immediate resuscitation is to maintain adequate tissue oxygenation

through adequate numbers of circulating red cells.

2. Check the full blood count and coagulation screen regularly.

3. Maintain haemoglobin >8 g/dL.

4. Maintain INR and APTT ratio <1.5 with fresh frozen plasma at 15 mL/kg.

5. Maintain platelet count >50 × 109/L with platelet transfusion.

6. Maintain fibrinogen >1 g/L with cryoprecipitate.

7. Consider tranexamic acid 2–3 g.

Other possible complications of blood transfusion:

Hypocalcaemia. Calcium gluconate (2 mL of 10% solution per unit of blood)

when calcium concentration is low or there are clinical signs or ECG changes.

Hyperkalaemia may occur due to its high concentration (approximately 40

mmol/L) in stored blood. This is usually only a problemin those with hepatic or renal

disease.

Acid–base disturbances. Despite the presence of lactic acid in transfused blood fluid

resuscitation, this usually improves acidosis in shocked patients. Furthermore,

transfused citrate produces an alkalosis once it is metabolised. Hypothermia. Warm

patient and blood.

Disseminated Intravascular Coagulation

DIC is caused by a stimulus that leads to abnormal and constant thrombin

generation16. Many etiologies for DIC exist, but the most severe, acute cases of DIC

are obstetrically related. Causes of DIC in pregnant women include amniotic fluid

embolus, infection and retained products of conception. While clinicians search for

the underlying cause of the DIC, the blood bank must provide product support before

and after the underlying cause is treated.

45

In addition to thrombin generation, DIC also results in activation of the

fibrinolytic system and abnormal amounts of plasmin are generated16. Thrombin

converts fibrinogen to fibrin, and plasmin not only digests cross-linked fibrin clots,

but also destroys fibrinogen before it is converted to fibrin. Therefore, DIC results in

a rapid, and disproportionate reduction in fibrinogen levels relative to other clotting

factors. Treatment must include rapid replacement of fibrinogen, and cryoprecipitate

is the ideal blood product for this purpose.

Laboratory findings will show the hallmarks of DIC. Most notably, no

detectable fibrinogen and extremely high D-dimer levels.

DIC is one of the most feared clinical conditions facing Transfusion Medicine

Services. Severe, acute DIC is most commonly related to obstetrical cases and has a

high mortality rate. Successful treatment must be directed at the underlying cause

and the blood bank must focus on rapid replacement of fibrinogen. This is best

accomplished with the use of adequate amounts of cryoprecipitate. Plasma and

platelets will also be required to provide the factors not contained in cryoprecipitate.

Factor VIII Concentrate:

One unit factor VIII/kg body weight will result in an increase in plasma factor VIII

level by 2%. The level of factor VIII concentrate required to achieve adequate

haemostasis will depend on the type of bleeding, but can be calculated according to

the formula:

Units of factor VIII required = weight (kg) × desired level (%) × 0.5

The plasma half-life of factor VIII is 8–12 hours and thus repeated doses at 12-hourly

intervals are usually needed.

DDAVP: (for mild disease only – baseline factor VIII above 15%).

46

Mild haemophilia A should be treated with DDAVP (with or without

tranexamic acid) rather than coagulation factor concentrates where possible. DDAVP

(0.3g/kg body weight) is given intravenously, subcutaneously. Hyponatraemia and

water intoxication are side effects of this drug, and hence it is not recommended for

patients with cardiac failure or children under 2 years of age.

Factor IX Concentrate:

One unit factor IX/kg body weight will result in an increase in plasma factor IX level

by 0.8%. The plasma half-life of factor IX is 18–30 hours, and therefore if repeated

doses are needed, they should be given every 12–24 hours.

Dose: Units of factor IX required = weight (kg) × desired level (%) × 0.8

Treatment of patients with inhibitors

Recombinant – activated factor VIIa: (rFIIa)

rFVIIa is approved for haemophiliacs with inhibitors to factor VIII or IX. In addition

now, it is approved for the management of

acquired haemophilia

congenital FVII deficiency

Glanzmans thrombasthenia with antibodies to GP IIb / IIIa or HLA and with

platelet refractoriness.

rVIIa binds to activated platelets and tissue factor. Coagulation occurs locally at the

site of bleeding without disseminate activation. Dose is 90microgm/kg. Higher dose

upto 300 microgm/kg is clinically more efficacious. Due to short half life dosing

interval in treating bleeding episodes is 2 – 4 hours. There is no increased risk of

thromboembolism.

Prothrombin complex concentrates (PCCs) are plasma-derived intermediate

purity products containing coagulation factors IX, X and II, and sometimes factor VII.

They are used for the reversal of severe over anticoagulation and/or bleeding due to

47

treatment with vitamin K antagonists (reversal of warfarin). They are also used for

the treatment of the severe rare bleeding disorders of factor X and factor II

deficiency. PCCs are now being used in patients with liver failure. In liver disease

PCCs can correct only part of the overall haemostatic abnormality, and carry a risk of

provoking DIC. DIC can also occur in patients without liver disease who are treated

with repeated doses of PCCs. Activated PCCs are used as ‘bypassing agents’, as an

alternative to recombinant factor VIIa, for the treatment of patients with severe

haemophilia with an inhibitor.

VonWillebrand Disease:

Patients with type 1 disease, DDAVP is the treatment of choice and a dose of

0.3g/kg body weight is usually given intravenously or subcutaneously. These doses

give a two to fivefold increase in vWF and factor VIII levels. Tranexamic acid is often

given in vWD.

For patients with types 2 and 3 diseases, vWF ‘replacement therapy’ is

generally required. Factor VIII concentrate rich in vWF, e.g Humate P / Alphante or

similar preparations is the treatment of choice. The recommended treatment goals

are similar to Factor VIIIc.It may be necessary to give single first dose of purified FVIII

concentrate to ensure immediate correction of the low FVIII levels in Type 1 patients.

If specific preparations are not available, cryoprecipitate can be used at a dose of 1

donor unit / 10 kg patient body weight.

48

9. Modified Red Cell Components

A-Leuco-depleted red cell components:

Until recently, little attention was paid to the leukocytes present in various

blood components. However, it has been shown that the removal of leukocytes from

various blood products can minimize the risks associated with these contaminating

leukocytes.

106 WBCs (3-4 log) reduction of leukocytes can be achieved by filtration and

apheresis by approved cell separators. Buffy coat method of component preparation

by automated blood component extractor gives 108 WBCs (1 log reduction) and to a

great extent minimize the FNHTRs, but it is not effective for preventing HLA

alloimmunization.

Removal leukocytes below the threshold of < 5X106 in blood components

helps in prevention of alloimmunization. Leuko depletion can be achieved with the

help of 3 or 4 th generation leukofiltes 1) pre storage in the blood bank, 2) post

storage in the patients bed side and 3) collection blood components with approved

cell separator machine. Pre storage leuko rdepletion eliminates accumulation of

inflammatory cytokines (interleukin 1, interleukin 6, tumour necrosis factor) released

by leukocytes during storage. Pre storage leuko depletion is quite effective in the

prevention of febrile nonhaemolytic transfusion reaction. Hence, pre storage leuko

depletion is most widely accepted.

Clinical benefits of leukocyte reduction

Proven benefits clinically relevant

Reduced frequency and severity of FNHTRs

Reduced risk of CMV transmission

Reduced risk of HLA alloimmunization and platelet refractoriness

Probably clinically relevant

Reducd infectious risk associated with immunomodulation (TRIM)

Reduced organ dysfunction and mortality

Reduced direct risk of transfusion transmissible bacteria

49

Packed red cell selective pre storage leukofiltration policy can be adopted for

patients who receive multiple transfusions such as thalassemics, hemodialysis

patients, aplastic anemia and hemato-oncology patients to prevent febrile

transfusion reactions to standard products.Platelet concentrates can be pooled and

leukofilterd pre storage for select group of haemato oncology patients.

B-Irradiated blood products:

In order to minimize the risk of transfusion associated graft versus host disease in

susceptible individuals, cellular blood products (PRBC, platelets) should be irradiated

to a dose of 25 Gy prior to transfusion. Red cells, platelets and granulocyte

components must be irradiated for all at-risk patients. It is not necessary to irradiate

fresh frozen plasma, cryoprecipitate, cryosupernatant or plasma derivatives. It is not

necessary to irradiate components for patients with solid tumours, organ

transplants, HIV or aplastic anaemia. Patient groups who should receive irradiated

blood products are as follows:

Transfusions from first- or second-degree relatives

Any granulocyte transfusion for any recipient

HLA-selected platelet units

Patients receiving purine analogues (fludarabine, cladribine, deoxycoformycin):

probably safer to use indefinitely

Intrauterine transfusion (IUT)

Exchange transfusion (provided that irradiation does not unduly delay transfusion)

Red cell or platelet transfusion in neonates – only if there has been a previous IUT or

if blood is from first- or second-degree relative

All recipients of allogeneic haemopoietic stem cell (HSC) grafts, from start of

conditioning therapy and while patient remains on GvHD prophylaxis

Blood transfused to allogeneic HSC donors before or during the harvest of their HSC

Patients who will have autologous HSC graft:

50

• any transfusion within 7 days of the collection of their HSC

• any transfusion from the start of conditioning therapy until:

3 months post transplant

6 months post transplant if conditioning TBI has been given

Hodgkin’s disease, at all stages of the disease

Congenital immunodeficiency with defective cell-mediated immunity (e.g. SCID, Di

George syndrome, Wiskott Aldrich syndrome, purine nucleoside deficiency, reticular

dysgenesis, ADA, Ataxia telangectasia, chronic mucosal candidiasis,

MHC class 1 or 2 deficiency)

51

ACUTE TRANSFUSION REACTIONS

Symptoms/signs of acute transfusion reaction Fever, chills; Tachycardia; hyper- or hypotension; collapse; rigors; flushing; urticaria; bone, muscle, chest and/or abdominal pain; shortness of breath; nausea; generally feeling unwell; respiratory distress

Stop the transfusion and call a doctor Measure temperature, pulse, blood pressure, respiratory rate, O2

saturation

Check the identity of the recipient with the details on the unit and compatibility label or tag

Febrile non-haemolytic transfusion reaction If temperature rise less than 1.5°C,

the observations are stable and the patient is otherwise well, give paracetamol

Restart infusion at slower rate and observe more frequently

Mild allergic reactions Give chlorphenamine 10mg slowly

iv and restart the transfusion at a slower rate and observe more

frequently Reaction involved mild fever or urticarial rash only

Mild Fever Urticaria

ABO incompatibility Stop transfusion

Take down unit and giving set

Return intact to blood bank

Commence iv saline infusion

Monitor urine output/catheterize

Maintain urine output at > 100 ml/hr

Give Furosemide if urine output falls/absent

Treat any DIC with appropriate blood components

Inform Blood transfusion department

immediately

Haemolytic reaction/bacterial infection of unit

Stop transfusion

Take down unit and giving set

Return intact to blood bank along with all other used/unused units

Take blood cultures, repeat blood group/crossmatch/FBC, coagulation screen, biochemistry, urinalysis

Monitor urine output

Commence broad spectrum antibodies if suspected bacterial infection

Commence oxygen and fluid support

Seek haematological and intensive care

advice

Fluid overload Give oxygen and frusemide 40-80mg iv

Severe allergic reactions Bronchospasm, angioedema, abdominal pain, hypotension

Stop transfusion

Take down unit and giving set

Return intact to blood bank along with all other used/unused units

Give chlopheniramine 10mg slow iv

Commence O2

Give salbutamol nebulizer

If severe hypotension, give adrenaline (0.5ml or 1 in 1000 intramuscular)*

Clotted sample to transfusion laboratory

Saline wash future components

Saline wash future components (*equivalent to 0.5 mg im)

Suspected ABO incompatibility

No

Yes

Severe Allergic reaction

Other haemolytic reaction/bacterial

contamination

Acute dyspnea/ hypotension Monitor blood gases perform CXR Measure

CVP/ pulmonary capillary

pressure

TRALI Clinical feature of acute

LVC with fever and chills

Discontinue transfusion

Give 100% oxygen

Treat as ARDS – ventilate

if hypoxia indicates

No

Yes

No

No

Yes

Raised

CVP

Normal

CVP

52

10. Transfusion Reactions

1. Types of reactions:

Acute hemolytic transfusion reaction

These reactions are generally due to ABO mismatch. Clerical errors, such as

misidentification of the patient, failure to match the ABO type on the

blood bag label with the blood group on patient’s file are the most

common causes. Anxiety, loin pain, chest pain, dyspnea, tachycardia

(increase more than 20% from baseline) and hypotension (fall more than

20% from baseline) soon after starting the transfusion are the presenting

symptoms.

Febrile hemolytic reaction

These are the most frequent type of reaction characterized by an increase

of 1 C or more in the patient’s temperature. These reactions are most

commonly seen in multiply transfused patients and follow after platelet

transfusion. Cytokines generated during storage of blood components and

anti-leucocytes antibodies in the recipient are responsible for these

reactions.

Allergic or Urticarial reactions

They are characterized by development of hives or skin rash following

transfusion. They are thought to be due to hypersensitivity reaction to

plasma proteins. Rarely, these reactions can lead to anaphylaxis.

Septic reactions

Transfusion of bacterial contaminated blood products can result in a

profound shock with high degree fever. They are characterized by high

fever, vomiting, diarrhea and severe hypotension. Can be more common

with platelet transfusion, due to its storage temperature.

TRALI: Transfusion related acute lung injury

Delayed Hemolytic Transfusion

53

DHTR is most often the result of an anamnestic response in a patient who

has previously been sensitized by transfusion, pregnancy, or transplant and

in whom antibody is not detectable by standard pre transfusion methods.

Clinical signs and symptoms are usually mild; severe DHTR cases and

fatalities are uncommon, unexpected or unexplained decreases in

hemoglobin or hematocrit values following transfusion should be

investigated as a possible DHTR.

Common Antibodies implicated in DHTR

Anti-Jka, Anti-E, Anti-D, Anti-C, Anti-K, Anti-Fya, Anti-M

Clinical Signs and Symptoms of DHTR

Common Signs and symptoms Unusual Signs and symptoms

Fever Hemoglobinemia

Anemia Hemoglobinuria

Mild Jaundice Shock

Renal failure

2. Action to be taken in the event of a reaction.

STOP THE TRANSFUSION IMMEDIATELY. Keep the Intravenous line open

with normal saline infusion.

Report the event to Resident and Consultant to determine whether the

transfusion is to be only temporarily or permanently discontinued.

If the transfusion is to be discontinued permanently, preserve the blood

bag with administration set removing the needle.

Complete the Reaction Report sent along with compatibility form.

It is the responsibility of the Clinical resident in charge to completely fill all

the details in the reaction form such as, vitals of the patients both pre

transfusion and post transfusion, time of start of transfusion, presence of

fever before transfusion, time of occurrence of reaction, amount of blood

54

transfused, any drug administered during transfusion and signs and

symptoms associated with transfusion.

Withdraw from the patient from a different site of transfusion, 2 ml EDTA

blood sample and 5 ml clotted blood in plain vial; label it with name of the

patient, Hospital number and POST REACTION SAMPLE.

The time of withdrawal of sample is important. The post reaction sample

should be withdrawn as early as possible and sent to the blood bank for

investigation. Delaying may result in loss of important finding which may

again result in adverse event during transfusion in the patient when

transfused.

The blood bag should be sent along with the transfusion set attached.

Transfusion Reactions Investigation form is available in Blood bank.

Send blood sample, implicated blood unit with administration set and

Reaction Report to the blood bank immediately for evaluation.

After completion of investigation, the blood bank Resident will notify the

clinical services of the results, offer advice for further transfusion and

suggestions for management.

Clinical judgment should be used to decide what reactions to investigate

more fully. Aggressive investigations of mild reactions can burden

resources within the health care settings and may cause unnecessary delay

in transfusion therapy for a patient in critical need of blood products. All

Blood transfusion reactions however minor should be brought to the

notice of the blood bank. The following algorithm can be used as a guide

for managing transfusion reactions. Summary of Transfusion Reactions is

enclosed in Appendix.

55

APPROACH FOR MANAGEMENT OF BLOOD TRANSFUSION REACTION

ALOGRITHM:

0. Transfusion

reaction

Severity of symptoms/sig

ns

Mild Severe

Consider following factors

- Patient’s reaction history - Co-morbid clinical factors - How much has been transfused? - Product leucocyte-reduced? - Product age is non-leucocyte-reduced

platelets

Immediately STOP the transfusion

Provide clinical support for the

patient

Perform bedside clerical check and notify the

transfusion laboratory

Should the transfusion be stopped

and investigated

NO

YES

Options include: -temporarily stop the transfusion, treat symptoms, resume transfusion when symptoms subside and monitor closely. -slow the rate of infusion, treat symptoms, monitor closely. Return the remainder of the

product to the laboratory for additional investigations that could include - Confirmation of bacterial

contamination (gram’s stain, cultures etc.)

- Screen for the haemolysis (caused by passive antibody infusion or transfusion of incompatible red cells)

- Consider TRALI, TACO, IgA deficiency.

Complete Transfusion Reaction Form and Send to the Transfusion Laboratory

Severe symptoms and/or signs include: hypotension fall > 20%, shortness of breath, haemoglobinuria,

nausea and vomiting, bleeding from IV sites (DIC), loin pain/chest pain, temperature, raise > 2° C

Moderate

56

11. Therapeutic Apheresis & Stem Cell Transplant

Therapeutic Plasma Exchange is performed for removal of circulating pathogenic

substance such as immune complexes, lipoproteins, toxins and antibodies. In this

procedure blood from patient is withdrawn anticoagulant added, separated in to

plasma and cellular components. The harmful plasma is discarded and replaced with

saline/FFP/albumin.

With one body plasma volume exchange 50% of pathogenic component is removed.

Hence, it is recommended that 40-50ml plasma/kg body weight should be removed in

one cycle, repeating the cycle 4 or 5 times over a period of 10-15 days. Plasma

exchange is a treatment of choice for TTP. The indications are given below:

Standard and acceptable indication for Therapeutic Plasma Exchange

1. Chronic inflammatory demyelinating polyneuropathy

2. Thrombotic thrombocytopenic purpura

3. Guillaian-Barre syndrome

4. Myasthenia gravis

5. Anti-GBM antibody disease (Goodpasture syndrome)

6. Hyperviscosity syndrome

7. Post transfusion purpura

8. Cryoglobulinemia

For carrying out Therapeutic Plasma Exchange prior intimation is necessary. The

clinical unit may contact Blood bank with request form duly filled in and signed by the

consultant. Therapeutic plasma exchange is not available for paediatric patients.

Haemotopoietic Stem Cells

Haemotopoietic Stem Cells can be obtained either from bone marrow or peripheral

blood. Peripheral blood stem cells (PBSC)are being increasingly used now. Using Cell

Separtors PBSC can be collected in a procedure lasting for 4 hours with venous access

without general anaethesia or hospitalization of donors.

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Sources of PBSC

1. Allogenic

Another sibling

Unrelated adults

Cord blood cells

2. Syngeneic – Identical twins

3. Autologous

Indications for PSBC Treatment

Allogeneic

Acute myeloid leukaemia: high risk/relapsed

Acute lymphoblastic leukaemia: high risk/relapsed

Chronic myeloid leukaemia

Myelodysplastic syndromes

Aplastic anaemia

Thalassemia major

Primary immune defi ciencies Autologous

Acute myeloid leukaemia: high risk/relapsed

Non-Hodgkin’s lymphoma, high grade/relapsed

Hodgkin’s disease: relapsed

Multiple myeloma

Germ cell cancer: relapsed

Ewing’s sarcoma: high risk/relapsed

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12. Good Blood Management Practice

The transfusion requirements in critical care (TRICC) study, the first and still

the most influential report on liberal transfusion policy delivered a clear conclusion –

improved patient survival was associated with a more restrictive transfusion regime.

This randomized trial of patients in intensive care showed that less severely ill patients

(Acute Physiology and Chronic Health Evaluation II score _<20) and patients under 55

years actually had a survival advantage if the Hb was maintained between 7 and 9 g/dL

rather than between 10 and 12 g/dl. For patients with clinically significant cardiac

disease the mortality was similar in both groups.

Three large retrospective studies have shown that receiving a perioperative

blood transfusion is an independent risk factor for short and long term survival

following cardiac surgery and avoiding transfusion could offer at least 5% improved

survival.

Perioperative correction of anaemia, intraoperative blood avoidance

interventions and a scrupulous attention to bloodless surgical technique must become

the standard of care.

The reasons for transfusion of blood should be recorded and review every

transfusion later on. This will enable efficient use of blood / blood components

transfusion for the benefit of patient. The model chart given below can be used.

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Transfusion decision Chart

Patient

Name ……………………………………… Age ……………………………….. Gender …………………… Hospital No. ……………………………. Date of assessment ………… Time ………………………. No Yes No Yes No

Yes No Action (based on the information you have recorded above) Doses of red cell concentrate to raise Hb by 1g/dL: ………………………………………………….. (Adult: 1 unit (200 mL)/50 kg raises Hb by 1-1.25g ) (Infant/child: 4 mL/kg raises Hb by 1-1.25g)

Decision: Transfuse ………………………. No ………………………. Yes …………………Units/mL Intended result: Clinical …………………………………………………….. [Hb] raise to: ……………………. g/dL Review of result Date: ……………………………… Time: ……………………………………... Clinical ……………………………………………………………... [Hb] ………………………………………..

Hb < 11

Signs and/or symptoms of inadequate O2 supply to tissues Pale …………………………………………

Breathless …………………................... Tachycardia. …………………………… Other …………………………………........

Expected Delivery ……………………………..

Bleeding …………………………….

Surgery ……………………………...

Haemolysis ………………………..

Bone marrow failure ………….

Other …………………………………

Hb g/dL

Sample date ………………………………..

Comorbidity

Malaria …………………………………

Sepsis …………………………………..

Fever ……………………………………

Haemolysis …………………………..

Leukaemia …………………………...

Ischaemic heart disease ………..

Other ……………………………………

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13. Maximum Surgical Blood Ordering Schedule

An MSBOS reduces workload, improves stock management and wastage.

Analyzing surgical procedures in terms of C:T ratio (crossmatch to transfusion), an

overall C:T ratio of 1.5 or less for elective surgery is achievable. For procedures in

which requirement of blood is only remote group and save request will be

appropriate, In case of group and save request irregular antibody screening will not

be done. In case of Type and screen request sample is screened for irregular antibody

and compatible blood can be made available within reasonable time.

An example of MSBOS is provided in the table below:-

MSBOS

G & S = Group and Save T & S = Type and Screen

OTORHINOLARYNGOLOGY – MSBOS

Acoustic tumor resection T & S Mastoidectomy, partial or total G & S

Angiofibroma, resection 2 Maxillectomy 2

Brachial cleft cyst, resection G & S Neurovascular reconstruction T & S

Caldwell-Luc procedure G & S Orbital exploration G & S

Carotid body tumor resection

2 Parotidectomy G & S

Craniofascial resection T & S Pharyngeal flap T & S

Cleft palate repair NS Radical neck dissection T & S

Ethmoidectomy G & S Retrolabyrinthine vestibular nerve resection

T & S

Glomus jugular tumor excision

2 Rhinoplasty G & S

Laryngectomy Simple T & S Temporal bone resection T & S

with radical neck T & S Tonsillectomy-adenoidectomy G & S

Mandibulectomy, hemi or total

2 Tracheostomy G & S

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GENERAL SURGERY - MSBOS

Amputation of limb (A/K OR B/K) T & S Gastrectomy, subtotal or total, with or without vagotomy

2

Aneurysm, abdominal 4 Gastroplasty, Mason (Gomez) T & S

Appendectomy T & S

Gastrostomy T & S

Breast Hemorrhoidectomy G & S

Biopsy

Mastectomy, simple or modified

Mastectomy, radical

TRAM

G & S

G & S

1

2

Hepatectomy 3

Hernia repair, all types T & S

Hodgkin’s or Lymphoma staging T & S

Laparotomy, exploratory T & S

Aorto-iliac or aorto-femoral 4 Parathyroidectomy T & S

Femoral-popliteal 2 Parotidectomy G & S

Carotid endarterectomy T & S Pilonidal cyst or sinus resection G & S

Cholecystectomy, with or without CBDE

T & S Renal transplant T & S

Colectomy 2 Shunt (portal hypertension) 6

Subtotal

Total or abdominal-perineal (AP)

2

3

Skin Graft, split thickness T & S

Splenectomy 1

Colostomy, revision or closure T & S Sympathectomy T & S

Embolectomy 2 Thyroidectomy T & S

Endovascular AAA 2 Tracheostomy T & S

Esophagectomy 4 Vagotomy and

pyloroplasty T & S

Pancreatectomy, partial or radical 3 Varicose vein stripping T & S

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NEUROSURGERY - MSBOS

Aneurysm, cranial 2 Laminectomy, cervical, thoracic or lumbar, for tumor

2

Anterior cervical diskectomy, with or without fusion

T & S Lumbar or cervical fusion, posterior

2

Carotid endarterectomy T & S Lumbar peritoneal shunt T & S

Carpal tunnel release G & S Child T & S

Cordotomy T & S Meningomyelocele repair T & S

Craniectomy for synostosis (child) 2

Peripheral nerve surgery other than carpal tunnel, tarsal tunnel and ulna nerve transposition

T & S

Craniotomy Stereotactic brain biopsy G & S

For AV malformation

For STA MCA or PICA bypass

For intracranial hematoma

For tumor

6

2

2

2

Syringoperitoneal shunt T & S

Child T & S

Tarsal tunnel release G & S

Ulnar nerve transposition G & S

Hypophysectomy T & S Ventriculoarterial shunt T & S

Laminectomy, lumbar, for disk T & S Ventriculoperitoneal shunt T & S

Laminectomy, cervical, thoracic or lumbar, for decompression

T & S

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CARDIAC AND THORACIC SURGERY - MSBOS

Aneurysm, thoracic, resection

4 Hernia repair

Atrial septal defect repair 2 All types including primary hiatus

T & S

Arterial switch operation 4 Recurrent hiatus T & S

Blalock-Tussig Shunt 1 Lobectomy pulmonary T & S

Coarctation of aorta repair

Child

Adult

1

2

Patent ductus arteriosus repair

T & S

Pericardectomy 2

Pneumonectomy T & S

Coronary bypass graft (CABG)

2 Tetralogy of Fallot Repair 4

CABG Redo 2 Tracheostomy T & S

Embolectomy 2 Valve replacement 4

Esophagectomy T & S Ventricular septal defect repair

4

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ORTHOPEDIC SURGERY - MSBOS

Amputation (A/K OR B/K) T & S Hip arthroplasty

Arthrotomy T & S First operation

Subsequent operations

2

4 Arthroscopy G & S

Cervical fusion 2 Hip disarticulation 4

Cervical laminectomy (disk) T & S Hip pinning 2

Fracture, open reduction Knee arthroplasty T & S

Hip 2 Laminectomy, lumbar T & S

Femur

Tibia

Forearm

2

T & S

T & S

Meniscectomy G & S

Osteotomy or bone biopsy

Femur

Tibia

2

T & S Fusion, lumbar or thoracolumbar

2

Hand surgery G & S Removal of knee pin T & S

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OBSTETRICS-GYNECOLOGY - MSBOS

Abortion, spontaneous, or termination

during first or second trimester G & S

Hysterectomy

Cervical conization G & S Vaginal

Vaginal with pelvic floor repair

Abdominal

Abdominal with Salpingo-oophorectomy

Radical

T & S

T & S

T & S

T & S

2

Cesarean section

Uncomplicated T & S

Vulvectomy, total or radical 2

After trial of forceps T & S

Cesium implant G & S Laparoscopy G & S

Deliveries, multiple (vaginal or abdominal

T & S Oophorectomy and ovarian wedge resection

G & S

Delivery accompanied by marked anemia

(Hb <10 gms ) or shock 2 Pelvic lymph node dissection 3

Ectopic pregnancy 2 Placenta previa under observation T & S

Examination under anesthesia (EUA) for

known or suspected placenta previa

2 Salpingo-oophorectomy G & S

High risk labor T & S Tubal ligation G & S

Placenta percreta/accreta 3 Tuboplasty G & S

Known or suspected placenta previa

2 Vaginectomy 2

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UROLOGY - MSBOS

PLASTIC SURGERY - MSBOS

Cleft palate repair G & S

Craniofacial procedure with intracranial comp

2

Mammoplasty

Augmentation G & S

Reduction G & S

TRAM T & S

Anthogerathic procedure with major steot

Otoplasty

Rhinoplasty

G & S

G & S

Skin flap T & S

Adrenalectomy 2 Prostatectomy

Cystectomy 4 Transurethral

Suprapubic

Perineal

Radical

T & S

2

2

4

Cystolithotomy G & S

Cystoscopy

Ileal loop

G & S

T & S

Kidney biopsy, open

T & S Renal artery repair 3

Meatotomy G & S Retroperitoneal lymph node dissection 2

Nephrectomy T & S TUR (Bladder Tumor) T & S

Radical Nephrectomy

4 Ureterostomy T & S

Orchiectomy G & S Uretero-vaginal or vesico-vaginal fistula repair

T & S

Penile implant T & S Urethroplasty G & S

Vesicopexy (ALL) T & S

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14. BIOSAFETY

1. All blood and blood components are to be considered potentially infectious

and Universal Precautions must be observed during handling of blood unit.

2. Discard the empty blood component bag in the Biohazard Waste Container in

the Ward, unless the patient has suffered from adverse reaction, then the

blood bag has to returned to the blood bank

3. If there is blood spillage, treat it as per the standard guidelines. Disinfect

blood spillage with 10% sodium hypochlorite solution. At least 30 minutes

should be allowed for hypochlorite solution to act during which spillage is

covered with gauze cloth soaked in hypochlorite.

4. All needles should be destroyed in the needle cutter and used syringes are

destroyed appropriately before discarding.

5. The sharps and needles should be discarded in a puncture proof container.

References:

1. Michael F. Murphy and Derwood H. Pamphilon (ed.). Practical Transfusion

Medicine,2009;

2. Morcela Contreras (ed.). ABC of Transfusion, 4th edition

3. Resident Manual, SGPGI, Lucknow.

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