introduction

•BLOOD TRANSFUSION IS DEFINED AS THE PROCESS OFRECEIVING BLOOD PRODUCTS INTO ONE’S CIRCULATIONINTRAVENOUSLY. THIS IS USUALLY DONE AS A LIFE SAVINGMANEUVER TO REPLACE BLOOD CELLS OR BLOOD PRODUCTSLOST THROUGH SEVERE BLEEDING, DURING SURGERY WHENSEVERE BLOOD LOSS OCCURS OR TO INCREASE THE BLOODCOUNT IN AN ANAEMIC PATIENT.

•TRANSFUSIONS USUALLY INVOLVE THE USE OF TWO SOURCES OFBLOOD – ONE’S OWN (AUTOLOGOUS TRANSFUSION) ORSOMEONE ELSE’S (ALLOGENIC TRANSFUSION).

•BLOOD TRANSFUSIONS INVOLVES THE USE OF WHOLE BLOOD ,RED BLOOD CELLS, WHITE BLOOD CELLS, PLASMA, CLOTTINGFACTORS AND PLATELETS.

Blood and blood products

•BLOOD IS COLLECTED FROM DONORS WHO HAVE BEEN PREVIOUSLYSCREENED TO EXCLUDE ANY BLOOD OR BLOOD PRODUCTS THAT MAYHAVE THE POTENTIAL TO HARM THE PATIENT.

•EACH UNIT OF BLOOD IS TESTED FOR EVIDENCE OF HEPATITIS-B,HEPATITIS-C , HUMAN IMMUNODEFICIENCY VIRUS I & II ANDSYPHILIS.

•THE ABO AND RHESUS D BLOOD GROUP IS DETERMINED AS WELL ASTHE PRESENCE OF IRREGULAR RED CELL ANTIBODIES.

•THE BLOOD IS THEN PROCESSED INTO SUB-COMPONENTS.

WHOLE BLOOD

•WHOLE BLOOD IS UNSEPARATED BLOOD CONTAINING ANANTICOAGULANT –PRESERVATIVE SOLUTION.

ONE UNIT OF WHOLE BLOOD CONTAINS -• 450 ml OF DONOR BLOOD.• 50 ml OF ANTICOAGULANT-PRESERVATIVE SOLUTION.• HAEMOGLOBIN approx. 12g/ml & HAEMATOCRIT 35% - 45%.• NO FUNCTIONAL PLATELETS.

•SINCE IT IS NOT STERILIZED, CAPABLE OF TRANSMITTING ANY AGENTPRESENT IN CELLS OR PLASMA WHICH HAS NOT BEEN DETECTED BYROUTINE SCREENING.

•HOWEVER WHOLE BLOOD TRANSFUSION HAS SIGNIFICANTADVANTAGES OVER PACKED CELLS AS IT IS COAGULATION FACTOR RICHAND IF FRESH, MORE METABOLICALLY ACTIVE THAN STORED BLOOD.

• STORED BETWEEN +2 AND +6 DEGREES CENTIGRATE IN A BLOODBANK REFRIGERATOR.

•TRANSFUSION SHOULD BE STARTED WITHIN 30 MINUTES OFREMOVAL FROM THE REFRIGERATOR AND COMPLETED WITHIN 4HOURS OF COMMENCEMENT BECAUSE CHANGES IN THECOMPOSITION MAY OCCUR DUE TO RED CELL METABOLISM.

INDICATIONS –•RED CELL REPLACEMENT IN ACUTE BLOOD LOSS WITHHYPOVOLAEMIA•EXCHANGE TRANSFUSION

CONTRAINDICATIONS –•CHRONIC ANAEMIA•INCIPIENT CARDIAC FAILURE

PACKED RED CELLS

•PACKED RED CELLS ARE CELLS THAT ARE SPUN DOWN ANDCONCENTRATED.

•ONE UNIT OF PACKED RED CELLS IS APPROX. 330 ml AND HAS AHAEMATOCRIT OF 50-70%.

•THEY ARE STORED IN A SAG-M (SALINE-ADENINE-GLUCOSE-MANNITOL) SOLUTION TO INCREASE THEIR SHELF LIFE TO 5 WEEKSAT 2-6 DEGREES CENTIGRATE.

•IT CARRIES THE SAME INFECTION RISK AS IN WHOLE BLOOD.

•INDICATED IN REPLACEMENT OF RED CELLS IN ANAEMIC PATIENTSAND ALSO USED WITH CRYSTALLOID AND COLLOID SOLUTIONS INACUTE BLOOD LOSS CONDITIONS.

FRESH FROZEN PLASMA

•FRESH FROZEN PLASMA IS RICH IN COAGULATION FACTORS.

•IT IS SEPARATED FROM WHOLE BLOOD AND STORED AT -40 TO -50DEGREES CENTIGRATE WITH A 2 YEAR SHELF-LIFE.

•IT IS THE FIRST LINE THERAPY IN THE TREATMENT OFCOAGULOPATHIC HAEMORRHAGE.

•ALSO USED IN THE REPLACEMENT OF MULTIPLE COAGULATIONFACTOR DEFICIENCIES LIKE LIVER DISEASE, WARFARIN OVERDOSE,DEPLETION OF COAGULATION FACTORS IN PATIENTS RECEIVINGLARGE VOLUME TRANSFUSIONS, DISSEMINATED INTRAVASULARCOAGULATION AND THROMBOTIC THROMBOCYTOPENIC PURPURA.

PRECAUTIONS –•ACUTE ALLERGIC REACTIONS ARE COMMON•SEVERE LIFE THREATENING ANAPHYLACTIC REACTIONS OCCASSIONALLY OCCUR.•DOSAGE – INITIAL DOSE OF 15ml/Kg.

Platelets

•PLATELETS ARE SUPPLIED AS A POOLED PLATELET CONCENTRATECONTAINING ABOUT 250 X 10 9 CELLS PER LITRE.

•PLATELETS ARE STORED ON A SPECIAL AGITATOR AND HAVE A SHELFLIFE OF ONLY 5 DAYS.

•ARE USUALLY GIVEN TO PATIENTS WITH THROMBOCYTOPENIA ORTHOSE WITH PLATELET DYSFUNCTION WHO ARE BLEEDING ORUNDERGOING SURGERY AND IN PATIENTS WITH BONE MARROWFAILURE.

•NOT INDICATED IN –• PATIENTS WITH ITP, TTP, UNTREATED DIC AND IN CASES OFHYPERSPLENISM.

•DOSAGE – 1 UNIT OF PLATELET CONCENTRATE /10 kg BODY WEIGHT.

•4-6 DONOR UNITS OF PLATELET CONCENTRATES WILL RAISE THEPLATELET COUNT BY 20-40 X 109/L. INCREMENT WILL BE LESS IF THEREIS ASSOCIATED SEPTICEMIA, DIC, SPLENOMEGALY.

•COMPLICATION S–FEBRILE AND ALLERGIC URTICARIAL REACTIONS ARE COMMONESPECIALLY IN PATIENTS RECEIVING MULTIPLE TRANSFUSIONS.

• PATIENTS ON ASPIRIN THERAPY RARLELY POSE A PROBLEM BUTTHOSE PATIENTS ON CLOPIDOGREL WHO ARE ACTIVELY BLEEDING ANDUNDERGOING MAJOR SURGERY MUST BE GIVEN A CONTINUOUSINFUSION DURING THE COURSE OF THE PROCEDURE.

CRYOPRECIPITATE

•CRYOPRECIPITATE IS A SUPERNATANT PRECIPITATE OF FRESH FROZEN PLASMA AND IS RICH IN FACTOR VIII AND FIBRINOGEN.

•IT IS STORED AT -30 DEGREES CENTIGRATE WITH A 2 YEARS SHELF LIFE.

•INDICATED IN LOW FIBRINOGEN STATES (<1g/L) OR IN CASES OF FACTOR VIII DEFICIENCY (HAEMOPHILIA-A), VON WILLEBRAND’S DISEASE AND AS A SOURCE OF FIBRINOGEN IN DISSEMINATED INTRAVASCULAR COAGULATION.

•POOLED UNITS CONTAINING 3-6 gms FIBRINOGEN IN 200-500 ml RAISES THE FIBRINOGEN LEVEL BY APPROX. 1g/L.

•MUST BE INFUSED WITHIN 6 HOURS.

BLOOD GROUPS AND CROSS-MATCHING

•HUMAN RED BLOOD CELLS HAVE MANY DIFFERENT ANTIGENS ON THEIR CELL SURFACE.

•TWO GROUPS OF ANTIGENS ARE OF MAJOR IMPORTANCE IN MEDICAL PRACTICE – THE ABO AND THE RHESUS SYSTEMS.

•ABO SYSTEM-THESE ARE STRONGLY ANTIGENIC AND ARE ASSOCIATED WITH NATURALLY OCCURING ANTIBODIES IN THE SERUM.THIS SYSTEM CONSISTS OF 3 ALLELIC GENES A,B & O.

•GROUP A & B CONTAIN SPECIFIC ANTIGENS AND PROVOKE A REACTION IF THESE ANTIGENS ARE NOT PRESENT IN THE RECIPIENT.

•GROUP ‘O’ CONTAINS NO ANTIGENS TO PROVOKE A REACTION IN THE RECIPIENT AND HENCE CALLED ‘AMORPHS’.

•THEREFORE, BLOOD GROUP ‘O’ IS CONSIDERED AS THE UNIVERSALDONOR AS IT HAS NO ANTIGENS TO PROVOKE A REACTION AND ‘AB’BLOOD TYPE IS CONSIDERED AS THE UNIVERSAL RECIPIENTS ASTHEY HAVE NO CIRCULATING ANTIBODIES TO THEM.

•RHESUS SYSTEM- THE RHESUS D ANTIGEN IS STRONGLY ANTIGENICAND IS PRESENT IN APPROXIMATELY 85% OF THE POPULATION.ANTIBODIES TO THE ‘D’ ANTIGEN ARE NATURALLY NOT PRESENT INTHE REMAINING 15% OF THE INDIVIDUALS BUT THEIR FORMATIONMAY BE STIMULATED BY THE TRANSFUSION OF RH’+’ RED CELLS ORTHEY MAY BE ACQUIRED DURING DELIVERY OF A RH-D-POSITIVEBABY LEADING TO HAEMOLYTIC DISEASE OF THE NEWBORN IN ASUBSEQUENT PREGNANCY.

MAKING THE

DECISION FOR

BLOOD

TRANSFUSION

•IF USED CORRECTLY, BLOOD TRANSFUSION CAN BE LIFE-SAVING,INAPPROPRIATE USE CAN ENDANGER LIFE.

•THE DECISION TO TRANSFUSE BLOOD OR BLOOD PRODUCTSSHOULD ALWAYS BE BASED ON A CAREFUL ASSESSMENT OF CLINICALAND LABORATORY INDICATIONS THAT TRANFUSION IS NECESSARYTO SAVE LIFE OR PREVENT SIGNIFICANT MORBIDITY.

minimising the need for blood

transfusion•Preoperative planning-•History and examination including surgical or bleeding history•Full blood count, blood chemistry, coagulation,•Consider autologous blood deposit•Consider erythropoietin to boost haemoglobin concentration•Treat iron or folate deficiency•Stop aspirin prophylaxis if possible•Day of admission•Check if taking aspirin, non-steroidal anti-inflammatory drugs,anticoagulants•Repeat full blood count•Consider drugs to reduce bleeding (such as aprotinin)

During surgery•Be prepared for longer duration to secure haemostasis•Consider hypotensive surgery if appropriate•Avoid hypothermia—give all fluids through a warmer•Consider fibrin glues and sealants

Postoperative care•Accept lower postoperative haemoglobin concentration•Accept transfusions of just one unit of blood, to exceed transfusiontrigger•Use continuous face mask oxygen if patient has low haemoglobinconcentration•Prescribe iron and folic acid routinely•Consider Tranexamic acid

•EXTERNAL BLEEDING & MEDICAL CONDITIONS LIKE THALASSEMIA.

•INTERNAL BLEEDING –Eg. VARICEAL BLEEDING,ECTOPIC PREGNANCY,ANTEPARTUM HAEMORRHAGE , RUPTURED UTERUS,TRAUMATIC INJURIES TO THE CHEST, SPLEEN, PELVIS, LUNGS, RED CELLDESTRUCTION AS IN MALARIA, SEPSIS, DISSEMINATED INTRAVASCULARCOAGULATION.

•CARDIORESPIRATORY STATE AND TISSUE OXYGENATION – BP, PULSE,RESPIRATORY RATE, CAPILLARY REFILL TIME, PERIPHERAL PULSES,TEMPERATURE, URINE OUTPUT, CARDIAC FAILURE.

•ASSESSMENT OF ANAEMIA – CLINICALLY FROM THE TONGUE, PALMS,EYES, NAILS AND FROM LABORATORY ASSESSMENT OF THE HAEMOGLOBINLEVEL OR HAEMATOCRIT.

•ANTICIPATED SURGERY WHERE POST-OPERATIVE BLOOD LOSS IS HIGHLYPROBABLE , CONTINUOUS BLEEDING OR LIKELIHOOD OF RECURRENCE OFBLEEDING, CONTINUING HAEMOLYSIS.

CAUSES OF ACUTE BLOOD LOSS IN AN

OBSTETRIC PATIENT•FETAL LOSS IN PREGNANCY – INCOMPLETE ABORTION, SEPTIC ABORTION.•ECTOPIC PREGNANCY – TUBAL, ABDOMINAL.•ANTEPARTUM HAEMORRHAGE – PLACENTA PREVIA, ABRUPTIO PLACENTAE, RUPTURED UTERUS, VASA PRAEVIA.•TRAUMATIC LESIONS – EPISIOTOMY, PERINEAL OR CERVICAL LACERATIONS, RUPTURED UTERUS.•POST-PARTUM HAEMORRHAGE – UTERINE ATONY, RETAINED PRODUCTS OF CONCEPTION, TRAUMATIC LESIONS, PUERPERAL SEPSIS, TISSUE DAMAGE FOLLOWING OBSTRUCTED LABOUR, BREAKDOWN OF UTERINE WOUND AFTER CAESAREAN SECTION.•DISSEMINATED INTRAVASCULAR COAGULATION INDUCED BY –IUFD, AMNIOTIC FLUID EMBOLISM, PRE-ECLAMPSIA, ABRUPTIO PLACENTAE, INDUCED ABORTION, RETAINED PRODUCTS OF CONCEPTION.

PERI-OPERATIVE RED BLOOD CELL

TRANSFUSION CRITERIA

HAEMOGLOBIN LEVEL g/dl

INDICATION

<6 Probably will benefit from transfusion

6-8 Transfusion unlikely to be of benefit in the absenceof bleeding or impending

surgery

>8 No indication for transfusion

Who Transfusion guidelines for chronic

anaemia during pregnancy

DURATION OF PREGNANCY HAEMOGLOBIN LEVEL CONSIDER IF-

<36 WEEKS 5.0 g/dl or LESS EVEN WITHOUT CLINICAL SIGNS OF CARDIAC FAILURE OR HYPOXIA

Hb 5.0-7.0g/dl + Established or incipient cardiac failure, Clinical evidence of hypoxia, Pneumonia or any serious bacterial infections, Pre-existing heart disease.

>36 WEEKS 6.0 g/dl OR LESS Hb 6.0 – 8.0 g/dl + Above mentioned conditions

ELECTIVE CAESAREAN SECTION

8.0-10.0 g/dl- Confirm blood group, Save freshly taken serum for cross-matching.

<8.0 g/dl – 2 Units of blood should be cross-matched and available.

Elective CS Planned + History of APH, PPH, Previous CS.

ESTIMATING BLOOD LOSS

•IN ORDER TO MAINTAIN BLOOD VOLUME ACCURATELY, IT ISESSENTIAL TO CONTINUALLY ASSESS SURGICAL BLOOD LOSSTHROUGHOUT THE PROCEDURE.

BLOOD VOLUME

NEONATES 85-90ml/kg Body Weight

CHILDREN 80ml/kg Body Weight

ADULTS 70ml/kg Body Weight

Example: An adult weighing 60 kgs would have a blood volume equal to 70x60, which is 4200 ml.

1. Weigh swabs while still in their dry state.2. Weigh the blood soaked swabs as soon as they are discarded

and subtract their dry weight (1ml of blood weighs approximately 1 gm).

3. Weigh the ungraduated drains or suction bottles and subtract their empty weight.

4. Estimate blood loss into surgical drapes, together with thatpooling beneath the patient and onto the floor.

5. Note the volume of any irrigation or wash out fluids that areused during surgery. Subtract this volume from the measuredblood loss to arrive at a final estimate.

• IN POST-OPERATIVE TRANSFUSION CASES, THE HAEMOGLOBINLEVEL, URINE OUTPUT, BLOOD PRESSURE, PULSE RATE, HEARTRATE, CAPILLARY REFILL TIME, COLOUR OF MUCOUSMEMBRANES, RESPIRATORY RATE AND SYMPTOMS AND SIGNSOF HYPOXIA SHOULD BE CAREFULLY MONITORED.

WHO ACCEPTABLE BLOOD LOSS GUIDELINE

METHOD HEALTHY PATIENT AVERAGE CLINICAL CONDITION

POOR CLINICAL CONDITION

PERCENTAGE METHOD –

Acceptable loss of blood volume

30% 20% <10%

HAEMODILUTION METHOD – Lowest

acceptable Haemoglobin or

Haematocrit

9g/dl or Haematocrit

= 27%

10g/dl or Haematocrit

= 30%

11g/dl or Haematocrit

=33%

During surgery, however the decision to transfuse will ultimatelyneed to be based on the careful assessment of Volume of bloodloss, Rate of blood loss, Patient’s clinical response to blood lossand fluid replacement therapy & signs indicating inadequate tissueoxygenation.

SAFE

BLOOD

TRANSFUSION

PROCEDURES

• EVERY HOSPITAL SHOULD HAVE WRITTEN STANDARD OPERATINGPROCEDURES FOR THE ADMINISTRATION OF BLOOD PRODUCTS LIKETHE ONE WE HAVE IN OUR HOSPITAL , PARTICULARLY FOR THE FINALIDENTITY CHECK OF THE PATIENT, THE COMPATIBILITY LABELDETERMINING THE PATIENT’S ABO AND RH-D GROUP, UNIQUEDONATION NUMBER OF THE BLOOD PACK, BLOOD GROUP OF THEBLOOD PACK, THE DATE OF COLLECTION AND THE EXPIRY DATE, THEINDICATION FOR TRANSFUSION, SIGNATURE OF THE CLINICIANPERFORMING THE PRE-TRANSFUSION IDENTITY CHECK AND THETRANSDUSION PROCEDURE

•THE BLOOD PACK SHOULD ALWAYS BE INSPECTED FOR SIGNS OFDETERIORATION ON ARRIVAL AND BEFORE TRANSFUSION IF NOT USEDIMMEDIATELY.

•DISCOLOURATION OF THE BLOOD PACK AND ANY SIGNS OF LEAKAGEINDICATE CONTAMINATION AND COULD CAUSE A SEVERE FATALREACTION IF TRANSFUSED.

DISPOSABLE EQUIPMENT FOR BLOOD ADMINISTRATION

• CANNULAS MUST BE STERILE AND MUST NEVER BE REUSED.• FLEXIBLE PLASTIC CANNULAS SHOULD BE USED AS THEY ARE SAFERAND PRESERVE THE VEINS.

FOR WHOLE BLOOD, RED CELLS, PLASMA & CRYOPRECIPITATE

•USE A NEW STERILE BLOOD ADMINISTRATION SET CONTAINING ANINTEGRAL 170-200 micron FILTER

• CHANGE THE SET AT LEAST 12 HOURLY DURING BLOOD COMPONENTINFUSION.

• IN A WARM CLIMATE, CHANGE THE SET MORE FREQUENTLY ANDUSUALLY AFTER EVERY 4 UNITS OF BLOOD IF GIVEN WITHIN A 12HOUR PERIOD.

• THERE IS NO EVIDENCE THAT WARMING BLOOD IS BENEFICIAL TOTHE PATIENT WHEN INFUSION IS SLOW. AT INFUSION RATES>100ml/minute, COLD BLOOD MAY BE A CONTRIBUTING FACTORIN CARDIAC ARREST. HOWEVER, KEEPING THE PATIENT WARM ISPROBABLY MORE IMPORTANT THAN WARMING THE INFUSEDBLOOD !

• WARMED BLOOD IS MOST COMMONLY REQUIRED IN LARGEVOLUME RAPID TRANSFUSIONS & EXCHANGE TRANSFUSION ININFANTS.

•BLOOD SHOULD ONLY BE WARMED IN A BLOOD WARMER THATHAVE A VISIBLE THERMOMETER AND AN AUDIBLE WARNINGALARM AND SHOULD BE PROPERLY MAINTAINED.

INTRAVENOUS CANNULATIONS FOR BLOOD TRANSFUSION CAN BEDONE FROM –

• CEPHALIC VEIN

• BASILIC VEIN

• FOREARM VEINS

• GREAT SAPHENOUS VEINS

MONITORING THE TRANSFUSED PATIENT

1. FOR EACH UNIT OF BLOOD TRANSFUSED, MONITOR THEPATIENT:

• BEFORE STARTING THE TRANSFUSION• 15 MINUTES AFTER STARTING THE TRANSFUSION• AT LEAST EVERY HOUR DURING TRANSFUSION• ON COMPLETION OF THE TRANSFUSION• 4 HOURS AFTER COMPLETING THE TRANSFUSION

2. AT EACH OF THESE STAGES, RECORD:• PATIENT’S GENERAL APPEARANCE• BLOOD PRESSURE, PULSE, RESPIRATORY RATE• FLUID BALANCE – ORAL AND IV FLUID INTAKE & URINARY

OUTPUT.

3. RECORD:• TIME WHEN THE TRANSFUSION IS STARTED.• TIME WHEN THE TRANSFUSION IN COMPLETED.• VOLUME AND TYPE OF ALL PRODUCTS TRANSFUSED.• BLOOD PACK NUMBERS.• ANY ADVERSE EFFECTS.

SEVERE REACTIONS MOST COMMONLY PRESENT IN THE FIRST 15-30MINUTES OF A TRANSFUSION THEREFORE THEY SHOULD BECLOSELY MONITORED DURING THIS TIME.

IF THE PATIENT APPEARS TO BE EXPERIENCING AN ADVERSEREACTION THE TRANSFUSION MUST BE IMMEDIATELY STOPPEDAND URGENT MEDICAL ASSISTANCE SHOULD BE SEEKED FOR.

REFERENCES:

• the who handbook on the clinical use of blood – who

blood transfusion safety , geneva , 2007.

• bailey & love’s short practice of surgery – 25th edition –

2008.

• davidson’s principle & practice of medicine – 21st edition –

2010.

• essential paediatrics – o.p. ghai – 6th edition.

• online text from the british medical journal –

www.bmj.co.uk/bloodtransfusionsafety31781/o3.