ClinicalTransfusionPractice

GuidelinesforMedicalInterns

Foreword
Bloodtransfusionisanimportantpartofdaytodayclinicalpractice.Bloodandbloodproducts
provide unique and lifesaving therapeutic benefits to patients. However, due to resource
constraints,itisnotalwayspossibleforthebloodproducttoreachthepatientattherighttime.
Themajorconcernfromthepointofviewofbothuser(recipient)andprescriber(clinician)isfor
safe,effectiveandqualitybloodtobeavailablewhenrequired.

Standardpracticesshouldbeinplacetoincludeappropriatetesting,carefulselectionofdonors,
screeningofdonations,compatibilitytesting,storageofdonationsforclinicaluse,issueofblood
units for either routine or emergency use, appropriate use of blood supplied or the return of
unitsnotneededafterissue,andreportsoftransfusionreactionsallaremajoraspectswhere
standardpracticesneedtobeimplemented.

Inordertoimplementguidelinesforstandardtransfusionpractices,acoordinatedteameffortby
clinicians, blood transfusion experts, other laboratory personnel and health care providers
involvedinthetransfusionchain,isneeded.

Orientation of standard practices is vital in addressing these issues to improve the quality of
bloodtransfusionservices.

Bedside clinicians and medical interns are in the forefront of patient management. They are
responsible for completing blood request forms, administering blood, monitoring transfusions
and being vigilant for the signs and symptoms of adverse reactions. These guidelines are
intendedtoenhancetheimplementationofstandardclinicaltransfusionpracticesforimproved
patientsafety.

ii

Acronyms

AHF

Antihaemophilicfactor

APTT

Activatedpartialthromboplastintime

DAT

Directantiglobulintest

DIC

Disseminatedintravascularcoagulation

FFP

FreshFrozenPlasma

Hb

Haemoglobin

HBV

HepatitisBvirus

Hct

Haematocrit

HCV

HepatitisCvirus

HDN

Haemolyticdiseaseofthenewborn

HIV

Humanimmunodeficiencyvirus

ITP

Idiopathicautoimmunethrombocytopenicpurpura

MOHFW

MinistryofHealthandFamilyWelfare

MTP

Massivetransfusionprotocol

PC

Plateletconcentrates

PRBC

Packedredbloodcells

PT

Prothrombintime

PTT

Partialthromboplastintime

SRO

StatutoryRegulationOrder

TACO

Transfusionassociatedcirculatoryoverload

TAGVHD

Transfusionassociatedgraftversushostdisease

TR

Transfusionreaction

TRALI

Transfusionrelatedacutelunginjury

TTIs

Transfusiontransmissibleinfections

TTP

Thromboticthrombocytopenicpurpura

iii

TableofContents
Foreword
Acronyms

iii
iv

Introduction

1.1
1.2

Principlesofclinicaltransfusionpractice
Safeblood

Screeningofblooddonations

2.1
2.2
2.3
2.4

7
7
7

Stepsinbloodscreening
Bloodsafetyinthehospitalsetting
Blooddonorrecruitment
Bloodcollection

9
9
9
10

Bloodcomponents

11

3.1
3.2
3.3
3.4
3.5

11
12
12
13
14

Wholeblood
Redcellconcentrates/packedredbloodcells
Plateletconcentrates
Freshfrozenplasma
Cryoprecipitatedantihaemophilicfactor

Storageofbloodcomponents

16

Clinicaltransfusionprocedure

17

5.1
5.2
5.3

17
17
17

Indicationsforbloodtransfusion
Transfusiontrigger
Responsibilityofattendingphysician

Administrationofbloodproducts

19

6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8

19
19
20
20
22
23
23
24
24
25
25

Bloodrequestform
Bloodsamples
Redcellcompatibilitytesting
Collectionandreceiptofblood
Performingthetransfusion
Monitoringthetransfusion
Documentationofthetransfusion
Otheraspectsoftransfusion
6.8.1 Warmingblood
6.8.2 Useofmedicationattimeoftransfusion
6.8.3 Useoffreshblood

Adverseeffectsoftransfusion

26

7.1
7.2
7.3
7.4
7.5

28
29
30
31
31

Guidelinesforrecognitionandmanagementofacutetransfusionreactions
Investigatingacutetransfusionreactions
Haemolytictransfusionreaction
Bacterialcontaminationandsepticshock
Transfusionassociatedcirculatoryoverload

iv

7.6
7.7
7.8

Anaphylacticreaction
Transfusionrelatedacutelunginjury
Delayedcomplicationsoftransfusion
7.8.1 Delayedhaemolytictransfusionreaction
7.8.2 Posttransfusionpurpura
7.8.3 Transfusionassociatedgraftversushostdisease
7.8.4 Delayedcomplications:transfusiontransmittedinfections

31
31
32
32
32
32
33

Massivebloodtransfusion

34

TransfusioninPaediatrics

36

9.1
9.2
9.3
9.4
9.5

36
37
38
39
39

10

BloodTransfusionServicesinBangladesh

Topuptransfusions
Exchangetransfusion
Haemolyticdiseaseofthenewborn
ABOhaemolyticdiseaseofthenewborn
TransfusionofplateletsandFFPinpaediatricpatients

43

Tables

Table1:Suggestedratesoftransfusion
Table2:Durationtimesfortransfusion
Table3:Category1:Mildreactions
Table4:Category2:Moderatelyseverereactions
Table5:Category3:Lifethreateningreactions
Table6:Parametersinmassivetransfusioninvestigationandmonitoring

22
22
28
28
28
34

Figures

Figure1:Bloodcoldchainfromcollectiontotransfusion
Figure2:Checkpointsforsignsofdeteriorationinbloodandplasma
Figure3:Hazardsofbloodtransfusion
Figure4:Crossmatchreportform
Figure5:Transfusionnotes
Figure6:Managementofadversetransfusionreaction:physiciansnotes

16
21
27
40
41
42

Introduction

Itiswellknownthaterrorsinbloodtransfusionpracticescanleadtoseriousconsequencesforthe
recipientintermsofmorbidityandmortality.Themajorityoferrorsoccurduetoincorrectsampling
of blood from a patient, fetching the wrong unit of blood for a patient and transfusing blood
inappropriately. These clinical transfusion guidelines describe protocols for the collection of blood
samplesforbloodgroupingandcrossmatching,andforthecollection,storageandadministrationof
bloodandbloodproducts.Theguidelinesprovideastandardizedapproachtotransfusionsothatthe
potentialforerrorsisminimizedandtheadministrationofsafeandefficaciousbloodproductsinthe
healthcaresettingismaximized.Theyalsocontainprotocolsfortheinvestigationandtreatmentof
adversetransfusionreactionsandprovideguidelinesfortheuseofspecialisedbloodproducts.

1.1 Principlesofclinicaltransfusionpractice

The patient with acute blood loss should receive effective resuscitation (intravenous replace
ment fluids, oxygen and other medication) immediately and the need for transfusion is
estimatedthereafter.

The patients haemoglobin (Hb) value, although important, should not be the sole deciding
factor in the decision to transfuse blood. This decision should be supported by the need to
relieveclinicalsignsandsymptomsandtopreventsignificantmorbidityormortality.

Clinicians shouldbe aware oftheriskoftransfusion transmissibleinfections in blood products

prescribedforpatients.

Transfusion should be prescribed only when the benefits to the patient are likely to outweigh
therisks.

Cliniciansshouldclearlyrecordthereasonfororderingatransfusion(clinicaldiagnosis).

Trained staff should monitor a patient undergoing transfusion and respond immediately there
aresignsofanadverseeffect.

1.2 Safeblood

Bloodfortransfusionisconsideredsafewhenitis:
Donatedbyacarefullyselected,healthydonor
Freefrominfectionsthatcouldbeharmfultotherecipient
Processedbyreliablemethodsoftesting,componentproduction,storageandtransportation
Transfusedonlyuponneedandforthepatientshealthandwellbeing

Thequalityandsafetyof bloodandbloodproductsmustbeassuredthroughouttheprocessfrom
theselectionofblooddonorstotheadministrationofbloodintothepatient.Thisisdescribedinthe
WHOBloodSafetyInitiative:

Establishmentofawellorganizedbloodtransfusionservicewithqualitysysteminallareas.
Collection of blood only from voluntary nonremunerated donors from lowrisk populations,
usingrigorousproceduresfordonorselection.
Screening of all donated blood for transfusion transmissible infections i.e. HIV, HBV, HCV,
syphilisandmalaria.

Good laboratory practice in all aspects of blood grouping, compatibility testing, component
preparationandthestorageandtransportationofbloodandbloodproducts.
Reductionofunnecessarytransfusionsthroughtheappropriateclinicaluseofbloodandblood
productsandtheuseofsimplealternativestotransfusionwhenpossible.

Transfusionofbloodandproductsshouldbeundertakenonlytotreataconditionthatwouldleadto
significant morbidly or mortality and that cannot be prevented or managed effectively by other
means.

ScreeningofBloodDonations

BloodscreeningbeganinBangladeshin2000atallhospitalbasedbloodtransfusioncentres.Itisthe
process that starts with the recruitment of safe blood donors and is followed by the mandatory
screeningforfivetransfusiontransmissibleinfections(TTIs)whichincludesHIV,HepatitisB,Hepatitis
C,syphilisandmalaria.TestingforTTIsstartedunderthepurviewoftheSafeBloodTransfusionAct
2002,whichstatesthatpriortotransfusion,allbloodanditsproductsmustundergotesting.

The objective of screening is to detect markers of infection, and prevent the release of infected
blood and blood components for clinical use. The assay selected for screening should be highly
sensitiveandspecific.Theaimistodetectallpossiblyinfecteddonationswhileminimizingwastage
duetofalsepositiveresults.Reactivedonationsthatareconfirmedpositive,orinwhichresultsare
indeterminate,shouldbediscardedusingmethodsinaccordancewithstandardsafetyprecautions.

2.1 Stepsinbloodscreening

PhysicalScreening
Blooddonorselection
Selfexclusion,deferral
Laboratorytesting
- Detectionofinfectionmarkers;eitherantibodyorantigen

2.2 Bloodsafetyinthehospitalsetting

Lowriskblooddonorrecruitment
Bloodscreening
Rationaluseofblood

2.3 Blooddonorrecruitment
It is recommended to collect blood from nonremunerated volunteer donors. The aim of using
selection guidelines for blood donors has two purposes: firstly, to protect donors from potential
harmwhichmayoccurasadirectresultofthedonationprocess;secondly,toprotectrecipientsof
bloodtransfusionfromadverseeffects,suchastransmissionofinfectiousdiseasesorothermedical
conditionsandunwantedeffectscausedbymedicationtakenbythedonor.InBangladesh,donors
areselectedaccordingthefollowingimportanteligibilitycriteria:

General appearance: the prospective donor shall appear to be in good physical and mental
health.
Age:donorsshallbebetween18and60yearsofage.
Haemoglobin:Hbshallbenotlessthan12.5g/dLformalesand11.5g/dLforfemales.
Weight:minimum45kg.
Blood pressure: systolic and diastolic pressures shall be normal (systolic: 100140mmHg and
diastolic:6090mmHgisrecommended),withouttheaidofantihypertensivemedication.
Temperature:oraltemperatureshallnotexceed37.5oC/99.5oF.
Pulse:pulseshallbebetween60and100beatsperminuteandregular.
Donationinterval:theintervalbetweenblooddonationsshallbe3to4months.

2.4 Bloodcollection

Thedonorshouldnotbefastingbeforedonation.Ifthelastmealwastakenmorethanfourhours
previously, the donor should be given something to eat and drink before donation. Blood flowing
into the bag is mixed with anticoagulant in a ratio of 1:7 (anticoagulant:blood). Total collection
volume is from 405495 mL and usually, a volume of 450 mL blood is donated, this being
approximately12%oftotalbloodvolumeor10.5mL/kgbodyweight.

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BloodComponents

Abloodcomponentisaconstituentofblood,separatedfromwholeblood,suchas:
Redcellconcentrate
Plasma
Plateletconcentrate
Cryoprecipitate,preparedfromfreshfrozenplasma;richinFactorVIIIandfibrinogen

A plasma derivative is made from human plasma proteins prepared under pharmaceutical
manufacturingconditions,suchas:
Albumin
Coagulationfactorconcentrates
Immunoglobulin

In Bangladesh, blood is generally collected in CPDA/CPDA1 blood bags that contain 63mL
anticoagulantsolutionwhichprovidesashelflifeforredcellsof35dayswhenstoredat+2Cto+6C.

ForcollectionofbloodcomponentsinBangladesh,doubleortriplebagsareused.Componentsare
prepared using a centrifuge, a piece of equipment that is available in most blood transfusion
departmentsofmedicalcolleges.

3.1 Wholeblood

Description:
450mLwholebloodin63mLanticoagulantpreservativesolutionofwhichHbwillbeapproximately
1.2g/dLandhaematocrit(Hct)3545%withnofunctionalplateletsorlabilecoagulationfactors(V
andVIII)whenstoredat+2Cto+6C.

Infectionrisk:
Capable of transmitting an agent present in cells or plasma which was undetected during routine
screeningforTTIs,i.e.HIV,hepatitisB&C,syphilisandmalaria.

Storage:
Between+2Cand+6Cinanapprovedbloodbankrefrigerator,fittedwithatemperaturemonitor
andalarm.

Indications:
Redcellreplacementinacutebloodlosswithhypovolaemia.
Exchangetransfusion.

Contraindications:
Riskofvolumeoverloadinpatientswith:
Chronicanaemia.
Incipientcardiacfailure.

Administration:
MustbeABOandRhDcompatiblewiththerecipient.
Neveraddmedicationtoaunitofblood.
Completetransfusionwithin4hoursofcommencement.
11

3.2 Redcellconcentrates[packedredbloodcells(PRBC)]

Description:
150200mLredbloodcellsfromwhichmostoftheplasmahasbeenremoved.Hbconcentrationwill
beapproximately20g/100mL(notlessthan45gperunit)andHct5575%.

Infectionrisk: Sameasforwholeblood.

Storage:
Sameasforwholeblood.

Indications: Replacementofredcellsinanaemicpatients.

3.3 Plateletconcentrates(PC)

Description:
PCs are prepared from units of whole blood that have not been allowed to cool below +20C. A
singledonorunitconsistsof5060mLplasmathatshouldcontain55x109platelets.

Unitofissue:
PCsmaybesuppliedasapooledunit,i.e.plateletspreparedfrom46donorunitscontainingatleast
240x109platelets.

Infectionrisk: Bacterialcontaminationaffectsabout1%ofpooledunits.

Storage:

PCsmaybestoredforupto5daysat+20Cto+24C(withagitation).PCsrequirecontinuousagitation
during storage, on a platelet shaker and in an incubator that maintains the required storage
temperature.

Dosage:

1 unit of platelet concentrate/10kg; for an adult of 6070kg, 46 single donor units containing at
least 240x109 platelets should raise the platelet count by 2040x109/L. Increment will be less if
thereissplenomegaly,disseminatedintravascularcoagulation(DIC)orsepticaemia.

Indications:
Treatmentofbleedingdueto:
Thrombocytopenia.
Plateletfunctiondefects.
Preventionofbleedingduetothrombocytopeniaasinbonemarrowfailure.

Contraindications:
Idiopathicautoimmunethrombocytopenicpurpura(ITP).
Thromboticthrombocytopenicpurpura(TTP).
UntreatedDIC.
Thrombocytopeniaassociatedwithsepticaemia,orincasesofhypersplenism.

Useinbonemarrowfailure:
Treatmentofbleeding,thrombocytopenicpatients.
Prophylacticuseinthrombocytopenicpatients.
- Maintainplateletcount>10x109/Linnonbleeding,noninfectedpatient.
- Maintainplateletcount>20x109/Lininfected/pyrexialpatient.
12

UseinDIC:
ForacuteDIC,wherebleedingisassociatedwiththrombocytopenia,maintainplateletcountabove
20x109/Levenintheabsenceofovertbleeding.

Useinmassivebloodtransfusion:
Maintain platelet count >50x109/L in patients receiving massive transfusions (dilutional thrombo
cytopeniaoccurswhen>1.5xbloodvolumeofpatientistransfused).

Useincardiopulmonarybypasssurgery:
Platelet function defects and thrombocytopenia often occur after cardiac bypass surgery.
Platelettransfusionisrecommendedforpatientswithbleedingnotduetosurgicallycorrectable
causes(closuretimeprovidesglobalindicationofplateletfunction).
Prophylacticplatelettransfusionsarenotrequiredforallbypassprocedures.

Prophylaxisforsurgery:
Ensure platelet count is >50x109/L for procedures such as lumbar puncture, epidural
anaesthesia, insertionofindwelling lines,transbronchialbiopsy,liverbiopsy,renal biopsyand
laparotomy.
Maintainplateletcount>100x109/Lforneurologicalandophthalmicsurgery.

Administration:
Platelet concentrates after pooling should be infused as soon as possible because of the risk of
bacterialproliferation.Dependingontheconditionoftherecipient,aunitshouldbeinfusedovera
periodofnotmorethan30minutes.DonotgiveplateletconcentratespreparedfromRhDpositive
donors to an RhD negative female with childbearing potential. Give platelet concentrates that are
ABOcompatible,wheneverpossible.

Complications:
Febrile nonhaemolytic and allergic urticarial reactions are not uncommon, especially in patients
receivingmultipletransfusions.

3.4 FreshFrozenPlasma(FFP)

Description:
FFPisplasmapreparedfromwholeblood,eitherfromtheprimarycentrifugationofwholebloodinto
redcellsandplasmaorfromasecondarycentrifugationofplateletrichplasma.Theplasmaisrapidly
frozen to 25C or colder within 8 hours of collection and contains normal plasma levels of stable
clotting factors, albumin, immunoglobulin and Factor VIII at a level of at least 70% of normal fresh
plasma.

Unitofissue:
200300mL.

Infectionrisk:
Capable of transmitting any agent present in cells or plasma which was undetected by routine
screeningTTIs,includingHIV,hepatitisBandC,syphilisandmalaria.

Storage:
FFP is stored at 25C or colder for up to 1 year. Before use, it should be thawed in the blood
transfusioncentrebetween+30Cand+37C.

13

Definiteindications:
Replacement of a single coagulation factor deficiency, where a specific or combined factor
concentrateisunavailableorcontraindicated.
Immediatereversalofwarfarineffectwhereprothrombincomplexconcentrateisunavailable.
Thromboticthrombocytopenicpurpura.
Inheritedcoagulationinhibitordeficiencieswherespecificconcentrateisunavailable.
C1esteraseinhibitordeficiencywherespecificconcentrateisunavailable.

Conditionalindications:
Massivebloodtransfusion.
AcuteDICiftherearecoagulationabnormalitiesandpatientisbleeding.
Liverdisease,withabnormalcoagulationandbleedingprophylacticusetoreduceprothrombin
time(PT)to1.61.8xnormalforliverbiopsy.
Cardiopulmonary bypass surgery use in the presence of bleeding but where abnormal coag
ulationisnotduetoheparin.Routineperioperativeuseisnotindicated.
Severesepsis,particularlyinneonates(independentofDIC).
Plasmapheresis.

Precautions:
Acuteallergicreactionsarenotuncommon,especiallywithrapidinfusions.
Severelifethreateninganaphylacticreactionsoccasionallyoccur.

Dosage:15mL/kg.

Administration:
ShouldbeABOcompatible.
Infuseassoonaspossibleafterthawing.
Labilecoagulationfactorsrapidlydegrade;usewithin6hoursofthawing.
FFPmaybebeneficialifPTand/orpartialthromboplastintime(PTT)>1.5timesnormal.
FFPforvolumeexpansioncarriesariskofinfectiousdiseasetransmissionandothertransfusion
reactions(e.g.allergic)thatcanbeavoidedbyusingcrystalloidorcolloidsolutions.

3.5 Cryoprecipitatedantihaemophilicfactor(CryoAHF)

Description:
CryoAHF is prepared from FFP by collecting the precipitate formed during controlled thawing at
+4Candresuspendingin1020mLplasma.Itisstoredat25Corcolderforupto1yearafterthe
dateofphlebotomy.CryoAHFcontainsabouthalftheFactorVIIIandfibrinogenasapackoffresh
wholeblood:e.g.FactorVIII:80100iu/pack;fibrinogen:150300mg/pack.

Infectionrisk:Asforplasma,butanormaladultdoseinvolvesatleast6donorexposures.

Storage:At25Corcolderforupto1year.

Indications:
AsanalternativetoFactorVIIIconcentrateinthetreatmentofinheriteddeficienciesof:
vonWillebrandFactor(vonWillebrandsdisease).
FactorVIII(haemophiliaA).
Asasourceoffibrinogeninacquiredcoagulopathies;e.g.DIC.
CanbeusedinisolatedFactorXIIIdeficiency.

14

 Ameliorateplateletdysfunctionassociatedwithuraemia.
Usedtopicallyasafibrinsealant.

Administration:
ABOcompatibleproductshouldbeused.
Afterthawing,infuseassoonaspossible.
Mustbetransfusedwithin6hoursofthawing.

15

Storageofbloodcomponents

Bloodmustnotbestoredinawardrefrigeratorunderanycircumstances.

Figure1:Bloodcoldchainfromcollectiontotransfusion

16

ClinicalTransfusionProcedure

5.1 Indicationsforbloodtransfusion

Toincreasetheoxygencapacityofbloodbygivingredcells.
Torestorethebloodvolumetomaintaineffectivetissueperfusion.
Toreplaceplatelets,coagulationfactorsandotherplasmaproteins.

Bloodmaybeneededinthefollowingcircumstances:

Bloodloss:
Bleeding
Trauma
Inadequateproduction:
Diseasessuchasthalassemia,leukaemia
Excessivedestructionofcells:
Disease
Mechanical

Transfusionofbloodandproductsshouldbeundertakenonlytotreataconditionthatwouldleadto
significantmorbidlyormortalitythatcannotbepreventedormanagedeffectivelybyothermeans.

Bloodismoreoftenneededunderthefollowingcircumstances:

Maternity:womenduringpregnancyandatthetimeofdelivery
Anaemiaofpregnancy;bleedinginpreorpostpartumstageofdelivery.
529years
Vulnerability during this age range due to infancy on the one hand (e.g. malnutrition,
malaria)andyouthontheother(e.g.natureofworkwhichmaybemorephysicalandmore
likelytoexposeindividualtoaccidents).
Patientswithchronicblooddisease
e.g.thalassemia,leukaemia.

5.2 Transfusiontrigger(adults)

One unit of whole blood/PRBC can increase Hb by 1g/dL in an adult or Hct by 3% (Hb of unit
mustbe>75%).
Perioperativetransfusion:
8g/dLforpatientundergoingcardiovascularsurgery,orthopaedicsandacuteGIbleeding.
Chronicanaemia:
7g/dLinadults.
Acutebloodloss:
30%ofvolumeofblood.

5.3 Responsibilitiesofattendingphysician

Assesspatientsclinicalneedforblood,andwhenrequired.
Informpatientand/orrelativesaboutproposedtransfusionandrecordinpatientsnotes.

17

Alsorecordindicationsfortransfusioninpatientsnotes.
Select blood product and quantity required (i.e. whole blood/PRBC/FFP/PC) and complete
requestformaccuratelyandlegibly.
Enter the reason for transfusion on the form, so that the blood centre can check that the
productorderedisthemostsuitablewithregardtodiagnosis.
Obtainandcorrectlylabelabloodsampleforcompatibilitytesting.
Sendthebloodrequestformandbloodsampletothebloodbank.
When the blood product that was ordered arrives, transfuse it as soon as possible to avoid
having to store it. However, if the blood product is not used immediately, store it under the
correctstorageconditions.
Crosschecktheidentityofthepatientandthebloodproduct:
Patientanddocumentation.
Blood/bloodproducts.

18

AdministrationofBloodProducts

When blood is transfused, it is important to keep detailed records including the following in the
patientsnotes:

Typeandvolumeofeachunittransfused.
Uniquedonationnumberofeachunittransfused.
Bloodgroupofeachunittransfused.
Timeatwhichthetransfusionofeachunitcommenced.
Signatureoftheindividualresponsibleforadministrationoftheblood.
Monitorthepatientbefore,duringandoncompletionofthetransfusion.
Recordthetimeofcompletionofthetransfusion.
Identifyandrespondimmediatelytoanyadverseeffect,bystoppingthetransfusion.
Recordthedetailsofanytransfusionreaction.

Theprocessstartswiththerequestforblood,followedbytheselectionofthecorrectbloodproduct
forcompatibilitytestingandfinallytheissuingofcompatiblebloodforinfusionintothepatient.

6.1 Bloodrequestform

Whenbloodisrequiredfortransfusion,theprescribingclinicianshouldcompleteandsignablood
request form that is designed to provide all necessary information. All details requested on the
bloodrequestformmustbecompletedaccuratelyandlegibly.

The blood request form should always be accompanied by the patients blood sample. The
sampleisplacedinasampletubethatiscorrectlylabelledandisuniquelyidentifiablewiththe
patient.
The blood sample shall not be submitted in a syringe, as this could lead to errors when
transferringtoatesttubeforgroupingandcompatibilitytesting.Itmayalsocausehaemolysis.
For a routine case, the sample and request form should be submitted to the transfusion
departmentatleast24hoursbeforerequired,tomakesureoftheavailabilityofblood.
Physiciansmayrequestthose,whoaccompanythepatient,toconsiderbecomingblooddonors
iftheyarehealthyandleadahealthylifestyle.

6.2 Bloodsamples

Thetakingofabloodsamplefromthepatientneedssupervision.Ifthepatientisconsciousatthe
time of taking the sample, ask him/her to identify himself/herself by given name and all other
appropriateinformation.

A5mLbloodsampleshouldbecollectedintoadrytesttubeandthencorrectlyandclearlylabelled
withthe patientsdetails,andsubmittedtothebloodcentrefortesting. The specimenlabelmust
includethefollowinginformation:

Patientsfullname,ageandsex.
Registrationnumber.
Ward/bednumber.
Dateandtimespecimentaken.
Phlebotomistssignature/initials.
19

Use positive patient identification to identify the patient. NEVER prelabel the sample
tubebeforephlebotomy.
Usethebloodproductrequestform,writelegiblyandfillinallappropriatedetails.
When taking a blood sample for cross match, complete the whole procedure before any
other task is undertaken it is important that there are no interruptions during the
process.
Thesignatureoftheindividualwhotookthesamplemustappearonthespecimenlabel.

Retentionofbloodsamples:
Blood samples from recipient and donor(s) must be retained for 7 days at +2C to +8C after
eachtransfusion.
Shouldanothertransfusionbenecessary72hoursaftertheearliertransfusion,afreshsample
shallberequestedforcrossmatch.Collectionofasecond5mLbloodsampleisrequiredforre
checkingandfurthercrossmatchingandmustberetainedincaseofinvestigationoftransfusion
reaction.

6.3 Redcellcompatibilitytesting

Thelaboratoryperforms:
ABOandRhDgroupingonpatientanddonors.
Antibodyscreeningonpatient.
Crossmatchingbetweenserumofpatientandredcellsofdonor.

These procedures normally take about an hour or more to complete. Shortened procedures are
possibleincaseofemergency,butmayfailtodetectsomeincompatibilities.

Thetermcompatibilitytestandcrossmatcharesometimesusedinterchangeably;theyshould
beclearlydifferentiated.
Thecrossmatchisthepartofpretransfusiontestknownascompatibilitytesting.
Thecompatibilitytestincludes:
- ABOandRhDgroupingofdonorandrecipient.
- Screeningforunexpectedantibodiesondonorandpatient.
- Crossmatch.
All pretransfusion test procedures should provide information on ABO and RhD grouping of both
patientandunitsofbloodtobetransfused.

Purposeofcompatibilitytesting:
To selectblood componentsthatwill causenoharmtotherecipientandwill have acceptable
survivalrateswhentransfused.
Whencorrectlyperformed,compatibilitytestswillconfirmABOcompatibilitybetweencomponent
andrecipientandwilldetectthemostclinicallysignificantunexpectedantibodies.
Compatibility (crossmatch) mustbeperformedbeforeblood is transfused. Thecrossmatch is
incompatibleifthereisareactionbetweenthepatientsserumanddonorsredcells.

6.4 Collectionandreceiptofblood

ALWAYS take a completed patient documentation label to the issue room of the blood trans
fusiondepartmentwhencollectingthefirstunitofblood.
MATCHthedetailsonthebloodrequestformagainstthebloodcompatibilitylabel(tag),thebag
unitnumberandthepatientdocumentationlabel.
Ifeverythingmatches,signouttheunitwiththedateandtime.
20

If there is any discrepancy, DO NOT sign out the unit; contact the staff member of the blood
transfusiondepartmentimmediately.
Whenreceivingtheunitofbloodintheclinicalarea,checkthatitistherightunitfortheright
patient.

Always check patient/component compatibility/identity. Inspect pack and contents for signs of
deteriorationordamage.

Figure2:Checkpointsforsignsofdeteriorationinbloodandplasma

Discolorationorsignsofanyleakagemaybetheonlywarningthatthebloodhasbeencontaminated
bybacteriaandcouldcauseasevereorfatalreactioniftransfused.

Bloodbagshouldbecheckedfor:
Anysignofhaemolysisintheplasmaindicatingthatthebloodhasbeencontaminated,allowed
tofreezeortowarm.
Anysignofhaemolysisonthelinebetweentheredcellsandplasmaduringstorage.
Anysignofcontamination,suchasachangeofcolourintheredcells,whichoftenlookdarker/
purple/blackwhencontaminated.
Anyclot,whichmaymeanthatthebloodwasnotmixedproperlywiththeanticoagulantwhenit
wascollectedormightalsoindicatebacterialcontaminationduetotheutilizationofcitrateby
proliferatingbacteria.
Anysignthatthereisaleakinthebagorthatithasalreadybeenopened.

Thebloodunitmustbediscardedif:
Ithasbeenoutoftherefrigeratorforlongerthan30minutes,or
Thesealisbroken,or
Thereisanysignofhaemolysis,clottingorcontamination.

21

6.5 Performingthetransfusion

Onceissuedbythebloodcentre,thetransfusionofwholeblood,redcells,plateletconcentrateand
thawedfreshfrozenplasmashouldbecommencedwithin30 minutesofremovalfromtheoptimal
storageconditions.

If thetransfusioncannot bestartedwithin thisperiod,the unit(s)mustbe stored underapproved

optimal storage conditions. The temperature inside every blood bank refrigerator used for whole
blood/ red cell storage should be monitored and recorded daily to ensure that the temperature
remains between +2C and +6C. If the ward or operating room does not have a blood bank
refrigeratorthatisappropriateforstoringblood,thebloodshouldonlybereleasedfromtheblood
centrejustbeforetransfusion.

Checkingthepatientsidentityandthebloodbagbeforetransfusion

Before starting the transfusion, it is vital to make the final identity check in accordance with the
hospitals standard operating procedure. The final identity check should be undertaken at the
patients bedside immediately before commencing the administration of the blood product. It
shouldbeundertakenbytwopeople,atleastoneofwhomshouldbearegisterednurseordoctor.

The finalcheckatthepatientsbedsideisthe lastopportunitytodetectanidentificationerrorand

preventapotentiallyincompatibletransfusion,whichmaybefatal.

Suggestedrateoftransfusion

Transfusion rate depends on clinical circumstances and may vary from 35 mL/kg/hour to greatly
increasedratesforindividualsinhypovolaemicshock.

Table1:Suggestedratesoftransfusion

Adults
Rate
Paediatricpatients
Rate
Wholeblood
150200mL/hour
Wholeblood/PRBC
25mL/kg/hour
PRBC
100150mL/hour
Platelets/plasma
12mL/minute
Platelets/plasma
150300mL/hour

Timelimitsfortransfusion

Thereisariskofbacterialproliferationorlossoffunctioninbloodproductsoncetheyhavebeen
removedfromthecorrectstorageconditions.
Transfusionofaunitofbloodshouldbecompletedwithinamaximumperiodoffourhoursafter
removalfromthebloodfridge:discardtheunitifthisperiodisexceeded.
If blood has been out of the blood bank refrigerator for more than 30 minutes and is not
transfused,thentheunitmustbereturnedtothelaboratory,whereitwillbedisposedof.

Table2:Durationtimesfortransfusion

Bloodproducts
Starttransfusion
Wholeblood/PRBC Within30minutes of
removingfromrefrigerator
Plateletconcentrate Immediately
FFP
Assoonaspossible
Cryoprecipitate
Assoonaspossible
22

Completetransfusion
4hours
Discardunitifthisperiodisexceeded
Within30minutes
Within30minutes
Within30minutes

Bloodadministrationset:

Useanew,sterilebloodadministrationsetcontaininganintegral170200filter.
Changethesetatleast12hourlyduringbloodtransfusion.
In a very warm climate, change the set more frequently and usually after every four units of
blood,ifgivenwithina12hourperiod.
Use a fresh blood administrationset orspecial platelettransfusionset,primedwith saline.All
bloodcomponentscanbeslowlyinfusedthroughsmallborecannulasorbutterflyneedles,e.g.
21to25G.Forrapidinfusion,largeborecannulas,e.g.14G,areneeded.

6.6 Monitoringthetransfusion

Itisessentialtotakebaselineobservationsandtoensurethatthepatientismonitoredduring
thetransfusioninordertodetectanyadverseeventasearlyaspossible.Beforecommencingthe
transfusion,itisessentialtoencouragethepatienttonotifyanurseordoctorimmediatelyifhe
orshebecomesawareofanydiscomfortsuchasshivering,flushing,painorshortnessofbreath
orbeginstofeelanxious.
Ensurethatthepatientisinasettingwhereheorshecanbedirectlyobserved.
Foreachunitofbloodtransfused,monitorthepatient:
- Beforestartingthetransfusion(baselineobservation).
- 15minutesafterstartingthetransfusion.
- Atleasteveryhourduringtransfusion.
- Carryoutafinalsetofobservations15minutesaftereachunithasbeentransfused.

6.7 Documentationofthetransfusion

Monitorthepatientbefore,duringandoncompletionofthetransfusion.

Ateachofthesestages,recordthefollowinginformationonthepatientschart:
- Patientsgeneralappearance.
- Temperature.
- Pulse.
- Bloodpressure.
- Respiratoryrate.

Makenoteofthefollowing:
- Timethetransfusionstarted.
- Timethetransfusionwascompleted.
- Volumeandtypeofbloodproductstransfused.
- Uniquedonationnumberofallproductstransfused.
- Anyadverseeffect.

Recordinthepatientsnotes:
Typeandvolumeofeachunittransfused.
Uniquedonationnumberofeachunittransfused.
Bloodgroupofeachunittransfused.
Timeatwhichthetransfusionofeachunitcommenced.
Signatureoftheindividualresponsibleforadministrationoftheblood.
Recordthetimeofcompletionofthetransfusion.
Recordthedetailsoftransfusionreaction.

Identifyandrespondimmediatelytoanyadverseeffect,bystoppingthetransfusion.
23

Severereactionsmostcommonlypresentduringthefirst15minutesofatransfusion.Allpatientsand
in particular, unconscious patients should be monitored during this period and for the first 15
minutesofeachsubsequentunit.

Specificinstructionsconcerningpossibleadverseeventsshallbeprovidedtothepatient.

Thetransfusionofeachunitofthewholebloodorredbloodcellsshouldbecompletedwithinfour
hoursofthestartofthetransfusion.Ifaunitisnotfullytransfusedwithinfourhours,discontinueits
useanddisposeoftheremainderthroughtheclinicalwastesystem.

Checkthatthefollowinginformationhasalsoberecordedinthepatientsnotes.

Whetherthepatientand/orrelativeswereinformedaboutthetransfusion.
Thereasonfortransfusion.
Signatureoftheprescribingclinician.
Pretransfusionchecksof:
- Patientsidentity.
- Bloodbag.
- Compatibilitylabel.
- Signatureofindividualperformingthepretransfusionidentitycheck.
Thetransfusion:
- Typeandvolumeofeachproducttransfused.
- Uniquedonationnumberofeachunittransfused.
- Bloodgroupofeachunittransfused.
- Timeatwhichthetransfusionofeachunitcommenced.
- Signatureofthepersonadministeringthebloodcomponent.
- Monitoringofthepatientbefore,duringandoncompletionoftransfusion.
- Allotherdetailsrelatedtothetransfusionprocess.
- Informedconsent.
- Administrationoftheunit.
- Setuptimeofeachunittransfused.
- Timeoftransfusion.

6.8 Otheraspectsoftransfusion

6.8.1 Warmingblood

Thereisnoevidencethatwarmingbloodisbeneficialtothepatientwhentransfusionisslow.
Attransfusionratesofgreaterthan100mL/minute,coldbloodmaybeacontributingfactorin
cardiacarrest.However,keepingthepatientwarmisprobablymoreimportantthanwarming
theblood.Warmedbloodismostcommonlyrequiredin:
Largevolumerapidtransfusions:
- Adults:morethan50mL/kg/hour.
- Children:morethan15mL/kg/hour.
Exchangetransfusionininfants.
Patientswithclinicallysignificantcoldagglutinins.
- Bloodshouldonlybewarmedinabloodwarmer.Bloodwarmersshouldhaveavisible
thermometerandanaudiblewarningalarmandshouldbeproperlymaintained.
- Bloodshouldneverbewarmedinabowlofhotwaterasthiscouldleadtohaemolysis
oftheredcellswhichcouldbelifethreateningwhentransfused.

24

6.8.2 Useofmedicationattimeoftransfusion

Itisgenerallynotrecommendedtoroutinelyusepremedicationlikeantihistamines,steroids
or other medication before transfusion. This practice may mask or delay the signs and
symptomsofanacutetransfusionreactionandthereforedelayrecognitionandactiontostop
thetransfusion.

Additionofmedicineorotherfluidswithbloodandbloodcomponents

Medicinesorotherfluidsshouldneverbeinfusedwithinthesamelineasbloodandblood
components.Theexceptionisnormalsaline(sodiumchloride0.9%)whichmaybeusedin
specialcircumstances,e.g.whentheflowisslowduetoincreasedHct,orwhensalineis
usedtopreparewashedredcells.
Use aseparate IVline ifanintravenousfluid hastobe given atthe same timeasblood
transfusion.

6.8.3 Useoffreshblood

Storedbloodlessthan7daysoldistermedfreshblood
Uses(toavoidbiochemicaloverload)toraiseHb:
- Renalandliverdysfunction.
- Patientrequiringmassivebloodtransfusion.
- Patient with raised plasma potassium due to extensive burns, or intravascular
haemolysis.
- Neonaterequiringexchangetransfusion.

Thereisnojustificationintransfusingwholebloodtostopbleedingduetocoagulopathiesinadults,
asitdoesnotcontainsufficientviableplatelets,orfibrinogen,orothercoagulationfactors.

Tostopbleeding,thespecificcomponentisneeded.FFP,PCsorcryoprecipitate,arethetreatments
ofchoicetostopbleeding.

Disadvantagesofusingbloodthathasnotbeenstoredbetween+2Cand+6C:

Increasedriskofdiseasetransmission:
- Intracellularpathogens(CMV,HTLV)surviveinleukocytespresentinfreshblood.
- Syphilistransmission:Treponemashouldnotsurvive>96hoursinstoredblood.
- Malariatransmission:malarialparasiteshouldnotsurvive>7hoursinstoredblood.

25

AdverseEffectsofTransfusion
The very first step is to stop the transfusion immediately. If the reaction is severe, the needle
shouldberemovedtopreventanyfurthertransfusionofblood.
All suspected acute transfusion reactions should be reported immediately to the blood
transfusioncentreandtothedoctorresponsibleforthepatient.Withtheexceptionofurticarial
allergic reactions and febrile nonhaemolytic reactions, all are potentially fatal and require
urgenttreatment.
Acutereactionsmayoccurin1%to2%oftransfusedpatients.Rapidrecognitionandmanage
mentofthereactionmaysavethepatientslife.Onceimmediateactionhasbeentaken,careful
andrepeatedclinicalassessmentisessentialtoidentifyandtreatthepatientsproblems.
Errors and failure to adhere to correct procedures are the common causes of lifethreatening
acutehaemolytictransfusionreactions.
Bacterial contamination in red cells or platelet concentrates is an underrecognized cause of
acutetransfusionreaction.
Patientswhoreceiveregulartransfusionsareparticularlyatriskofacutefebrilereactions.These
shouldberecognizedsothattransfusionisnotdelayedorstoppedunnecessarily.
Transfusiontransmittedinfectionsaretheseriousdelayedcomplicationsoftransfusion.Sincea
delayed transfusion reaction may occur days, weeks or months after the transfusion, the
associationwiththetransfusionmaynotberecognised.
The transfusion of a large volume of blood and intravenous fluids may cause haemostatic
defects or metabolic disturbances in the patient. There should be an availability of various
treatments including oxygen, adrenaline, corticosteroids, bronchodilators, diuretics and an
emergencyteam.

Inanunconsciousoranaesthetizedpatient,hypotensionanduncontrolledbleedingmaybetheonly
signofanincompatible(mismatched)transfusion.Inaconsciouspatientundergoinganacutesevere
haemolytictransfusionreaction,signsandsymptomsmayappearwithinminutesoftransfusionof5
10mLofblood.Closeobservationatthestartofthetransfusionofeachunitisthereforeessential.

26

Figure3:Hazardsofbloodtransfusion

Transfusionreaction(TR)

AcuteTR(<24hours)
- Wrongblood,primedimmunologicalrecipient
- Poorqualityblood,faultyassessment
DelayedTR(>24hours)
- Diseases,otherdelayedimmunologicreactions,metaboliceffect(510days)

InvestigationofasuspectedTR

TRs may be acute or delayed. Acute reactions range from a nonspecific febrile episode to life
threatening intravascular haemolysis. All suspected transfusion reactions should therefore be
assessedandtreatedappropriately.

Ifanacutetransfusionreactionissuspected,stopthetransfusionimmediately.
Checkthebloodbaglabelagainstthepatientsidentity.
Ifthereactionissevereormisidentificationisconfirmedonchecking,removetheneedle.
Ifthereactionismild,keeptheIVlineopenwithaninfusionof0.9%sodiumchloride.
Atthesametime,callforassistance;notifythebloodbankandtheseniorinchargeoftheward.

Withtheexceptionofurticarialallergicandfebrilenonhaemolyticreactions,allarepotentiallyfataland
requireurgenttreatment.Theseverityofthereactionandthedegreeofmorbidityisusuallyrelatedtothe
volumeofbloodtransfused.

Theonlysigninanunconsciousoranesthetizedpatientmaybehypotensionanduncontrolledbleedingor
oozing.Inaconsciouspatientthismayoccurwithinminutesoftransfusionofaslittleas510mLblood.
27

7.1 Guidelinesforrecognitionandmanagementofacutetransfusionreactions

Table3:Category1:Mildreactions
Signs
Symptoms
Possiblecause
Localizedcutaneous:
Pruritus
Hypersensitivity
Urticaria
(mild)
Rash

ImmediatemanagementofCategory1:Mildreactions
Slowthetransfusion.
AdministerantihistamineIM.
Ifnoclinicalimprovementwithin30minutesorifsignsandsymptomsworsen,treatasCategory2.
Ifimproved,restarttransfusionslowly.

Table4:Category2:Moderatelyseverereactions
Signs
Symptoms
Possiblecause
Hypersensitivity
Anxiety
Flushing
Pruritus
Urticaria
Palpitations
Rigors
Milddyspnoea
Fever
Headache
Restlessness
Tachycardia

ImmediatemanagementofCategory2:Moderatelyseverereactions
StopthetransfusionandkeepIVlineopenwithnormalsalineinanothersite.
Returnthebloodunitwithtransfusionadministrationset,freshlycollectedurineandnewblood
samples(1clottedand1anticoagulated),drawnfromaveinoppositetothetransfusionsite,to
thebloodtransfusioncentreforlaboratoryinvestigations.
Administer antihistamine IM and oral or rectal antipyretic. Avoid aspirin in thrombocytopenic
patients.
Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. broncho
spasm,stridor).
If clinical improvement occurs, restart transfusion slowly with new blood unit and observe
carefully.
Ifnoclinicalimprovementwithin15minutesorifsignsandsymptomsworsen,treatasCategory3.
Collecturinefornext24hoursforevidenceofhaemolysisandsendforlaboratoryinvestigations

Ifavailable,aleucocytereductionfilter(WBCfilter)maybeusedinrepeatedtransfusion.

Table5:Category3:Lifethreateningreactions
Signs
Symptoms
Possiblecause
Acuteintravascularhaemolysis
Anxiety
Rigor
(mismatchedbloodtransfusion)
Chestpain
Fever
Painalongthetransfusionline Bacterialcontaminationand
Restlessness
Respiratorydistress/shortness septicshock
Hypotension(fallof20%in
ofbreath
systolicBP)
Fluidoverload
Loin/backpain
Tachycardia(riseof20%in
Anaphylaxis
Headache
heartrate)
Transfusionrelatedacutelung
Haemoglobinuria(Hbinurine) Dyspnoea
injury(TRALI)

Unexplainedbleeding(DIC)

28

ImmediatemanagementofCategory3:Lifethreateningreactions

StopthetransfusionandkeepIVlineopenwithnormalsalineinanothersite.
InfusenormalsalinetomaintainsystolicBP.
Maintainairwayandgivehighflowoxygenbymask.
Giveadrenaline(as1:1000solution)0.01mg/kgbodyweightbyslowintramuscularinjection.
GiveIVcorticosteroidsandbronchodilatorsifthereareanaphylactoidfeatures.
Givediuretic:e.g.frusemide1mg/kgIVorequivalent.
Checkafreshurinespecimenvisuallyforsignsofhaemoglobinuria.
Notifythesuperiororseniordoctorattendingthepatient,andthebloodcentreimmediately.
Sendbloodunitwithtransfusionset,freshurinesampleandnewbloodsamples(1clottedand1
anticoagulated),drawnfromaveinoppositetheinfusionsite,withtheappropriaterequestform
tothebloodtransfusioncentreforinvestigation.
Starta24hoururinecollectionandrecordallintakeandoutput.Maintainfluidbalancechart.
Assessforbleedingfrompuncturesitesorwounds.Ifthereisclinicalorlaboratoryevidenceof
DIC,giveplatelets(adult:46units)andeithercryoprecipitate(adult:12units)orFFP(adult:3
units).
Reassess.Ifhypotensive:
Givefurthersaline.
Giveinotrope,ifavailable.
If urine output falls or there is laboratory evidence of acute renal failure (rising K+, urea,
creatinine):
Maintainfluidbalanceaccurately.
Givefurtherdiuretic:e.g.frusemide1mg/kgIVorequivalent.
Considerdopamineinfusion,ifavailable.
Seekexperthelp:thepatientmayneedrenaldialysis.
Ifbacteraemiaissuspected(rigor,fever,collapse,noevidenceofahaemolyticreaction),starta
broadspectrumantibioticIV.

7.2

Investigatingacutetransfusionreactions

Immediately report all acute transfusion reactions, with the exception of mild hypersensitivity
(Category1)tothedoctorresponsibleforthepatientandtothebloodtransfusioncentrethat
supplied the blood. If a severe lifethreatening reaction is suspected, seek help immediately
from the blood transfusion expert/anaesthetist/emergency team/whoever is available and
skilledtoassist.
Recordthefollowinginformationonthepatientsnotes:
Typeoftransfusionreaction.
Timelapsebetweenstartoftransfusionandwhenreactionoccurred.
Volume,typeandbagnumberofbloodproductstransfused.

Immediatelytakeposttransfusionbloodsamples(1clottedand1anticoagulated)fromthevein
oppositethetransfusionsiteandforwardtothebloodcentreforinvestigationofthefollowing:

RepeatABOandRhDgroup.

Repeatantibodyscreenandcrossmatch.

Fullbloodcount.

Coagulationscreen.

Directantiglobulintest.

Ureaandcreatinine.

Electrolytes.
29

Alsoreturnthefollowingtothebloodcentre:

Bloodbagandtransfusionsetcontainingredcellandplasmaresiduesfromthetransfused
unit.

Bloodcultureinaspecialbloodculturebottle.

Firstspecimenofthepatientsurinefollowingthereaction.

Completedtransfusionreactionreportform.

Aftertheinitialinvestigationofthereaction,sendpatients24hoururinesampletotheblood
transfusioncentreforlaboratoryinvestigation.
Recordtheresultsoftheinvestigationsforfuturefollowup,ifrequired.

7.3 Haemolytictransfusionreaction

Anacutehaemolytictransfusionreactionistheresultofamismatchedbloodtransfusion,andcauses
acuteintravascularhaemolysis.

Acute intravascular haemolytic reaction is caused by the transfusion of incompatible red cells,
i.e.mismatchedblood.Antibodiesinthepatientsplasmahaemolysetheincompatibleredcells
transfused.
Even a small volume (510 mL) of incompatible blood can cause a severe reaction and larger
volumeincreasestherisk.
ThemostcommoncauseofreactionisABOincompatibletransfusion.Thisalmostalwaysarises
from:
Errorsinthebloodrequestform.
Takingbloodfromthewrongpatientintoaprelabelledsampletube.
Incorrectlabellingofthebloodsampletubesenttothebloodtransfusioncentre.
Inadequatecheckingofthebloodlabelagainstthepatientsidentity.
Antibodiesinthepatientsplasmaagainstotherredcellantigenspresentontransfusedblood,
suchasthoseoftheKidd,KellorDuffybloodgroupsystems,canalsocauseacutehaemolysis.
Intheconsciouspatient,signsandsymptomsusuallyappearwithinminutesofcommencingthe
transfusion,sometimeswhen<10mLbloodhasbeengiven.
Inanunconsciousoranaesthetizedpatient,hypotensionanduncontrollablebleeding,fromthe
transfusionsite,maybetheonlysignofanincompatibletransfusion.
Itisthereforeessentialtomonitorthepatientfromthecommencementofthetransfusionupto
itscompletion.

Prevention:
Correctlylabelbloodsampleandrequestform.

Placethepatientsbloodsampleinthecorrectsampletube.

Alwayscheckthebloodunitagainsttheidentityofthepatientatthebedsidebeforetransfusion.

30

7.4 Bacterialcontaminationandsepticshock

Bacterialcontaminationaffectsupto0.4%ofredcellsand12%ofplateletconcentrates.
Bloodmaybecomecontaminatedby:
- Bacteria from the donors skin entering the blood unit during collection (usually
staphylococci).
- Bacteraemiapresentinthebloodofthedonorduringcollection(e.g.Yersinia).
- Improperhandlingduringbloodprocessing.
- Defectordamagetothebloodbag.
- ThawingFFPorcryoprecipitateinawaterbath(oftencontaminated).
Somecontaminants,particularlyPseudomonasspecies,growat+2Cto+6Candcansurviveor
multiplyinrefrigeratedredcellunits.
StaphylococcigrowinwarmerconditionsandareabletoproliferateinPCswhicharestoredat
+20Cto+24C.
Signsusuallyappearrapidlyafterstartinginfusion,butmaybedelayedforafewhours.
Aseverereactionmaybecharacterizedbysuddenonsetofhighfever,rigorsandhypotension.
Urgentsupportivecareandhighdoseintravenousantibioticsarerequired.

7.5

TransfusionAssociatedCirculatoryOverload

Transfusionassociatedcirculatoryoverload(TACO),i.e.fluidoverload,canresultinheartfailure
andpulmonaryoedema.
Mayoccurwhen:
- Toomuchfluidistransfused.
- Thetransfusionisgiventoorapidly.
- Renalfunctionisimpaired.
Fluidoverloadisparticularlylikelytohappeninpatientswith:
- Chronicsevereanaemia.
- Underlyingcardiovasculardisease.

7.6

Anaphylacticreaction

Thisisararecomplicationoftransfusionofbloodcomponentsorplasmaderivatives.
Theriskisincreasedbyrapidinfusion,typicallywhenfreshfrozenplasmaisused.
IgAdeficiencyintherecipientisararecauseofverysevereanaphylaxis.Thiscanbecausedby
anybloodproductsincemostcontaintracesofIgA.
Cytokines in the plasma may occasionally cause bronchoconstriction and vasoconstriction in
recipients.
Occurswithinminutesofstartingthetransfusionandischaracterizedby:
- Cardiovascularcollapse.
- Respiratorydistress.
- Nofever.
Anaphylaxisislikelytobefatalifitisnotmanagedrapidlyandaggressively.

7.7 TransfusionRelatedAcuteLungInjury

Transfusion related acute lung injury (TRALI) is usually caused by donor plasma that contains
antibodiesagainstthepatientsleucocytes.

31

Rapid failure of pulmonary function usually presents within 14 hours of starting transfusion,
withdiffuseopacityonthechestXray.
Thereisnospecifictherapy.Intensiverespiratoryandgeneralsupportinanintensivecareunitis
required.

7.8 Delayedcomplicationsoftransfusion

7.8.1 Delayedhaemolytictransfusionreaction
Signsappear510daysaftertransfusion:
Fever.
Anaemia.
Jaundice.
Occasionallyhaemoglobinuria.

Severe,lifethreateningdelayedhaemolytictransfusionreactionswithshock,renalfailureand
DICarerare.

7.8.2 Posttransfusionpurpura
This is a rare but potentially fatal complication of transfusion of red cells or platelet
concentrates, caused by antibodies directed against plateletspecific antigens in the
recipient.
Mostcommonlyseeninmultigravidafemalepatients.
Signsandsymptoms:
Signsofbleeding.
Acute, severe thrombocytopenia 510 days after transfusion, defined as a platelet
countof<100x109/L.

Management
Managementbecomesclinicallyimportantataplateletcountof50x109/L,withadangerof
hidden(occult)bleedingat20x109/L.
Givehighdosecorticosteroids.
GivehighdoseIVimmunoglobulin,2g/kgor0.4g/kgfor5days.
Plasmaexchange.
Monitorthepatientsplateletcount:normalrangeis150x109/Lto440x109/L.
If available, give platelet concentrates that are negative for the plateletspecific antigen
againstwhichtheantibodiesaredirected.
Unmatchedplatelettransfusionisgenerallyineffective.
Recoveryofplateletcountafter24weeksisusual.

7.8.3 Transfusionassociatedgraftversushostdisease(TAGVHD)

UnliketransplantassociatedGVHD,TAGVHDitisusuallyafatalcondition.
Occursinpatientssuchas:
Immunodeficientrecipientsofbonemarrowtransplants.
Immunocompetentpatientstransfusedwithbloodfromindividualswithwhomthey
haveacompatibleHLAtissuetype,usuallybloodrelativesparticularly1stdegree.
Signsandsymptomstypicallyoccur1012daysaftertransfusionandarecharacterizedby:
Fever.
Skinrashanddesquamation.
Diarrhoea.
Hepatitis.
Pancytopenia.
32

Management
Treatmentissupportive;thereisnospecifictherapy.
Prevention
Do not use 1st degree relatives as donors, unless gamma irradiation of cellular blood
componentsiscarriedouttopreventtheproliferationoftransfusedlymphocytes.

7.8.4 Delayedcomplications:transfusiontransmittedinfections

Thefollowinginfectionsmaybetransmittedbytransfusion:
HIV,HepatitisBandC,syphilis(Treponemapallidum),malaria.
Cytomegalovirus(CMV).
OtherTTIs includehuman parvovirusB19, brucellosis, EpsteinBarr virus,toxoplasmosis,
Chagasdisease,infectiousmononucleosisandLymesdisease.

Sinceadelayedtransfusionreactionmayoccurdays,weeksormonthsafterthetransfusion,
the association with the transfusion may easily be overlooked. It is essential to record all
transfusions accurately in the patients case notes and to consider transfusion in the
differentialdiagnosis.

33

MassiveBloodTransfusion

Massivebloodtransfusionmaybedefinedasthereplacementofonebloodvolume(equivalentto
10unitsofblood)inany24hourperiod,orhalfofthebloodvolume(5unitsofblood)inanyfour
hourperiodinanadult.

Replacementofabloodvolumeequivalentwithin24hours.
>10unitswithin24hours.
Transfusion>4unitsin1hour.
Replacementof50%ofbloodvolumein34hours.
Arateofloss>150ml/hour.

Massivetransfusionoccursinsettingssuchasseveretrauma,rupturedaorticaneurysm,surgeryand
obstetric complications. The goals to the management of massive transfusion include early
recognition of blood loss, maintenance of tissue perfusion, oxygenation by restoration of blood
volume and Hb, and the cessation of bleeding by several means including early surgical or
radiological intervention, and the judicious use of blood component therapy to correct
coagulopathy.

Plasmaundergoesprogressivelossofcoagulationfactorsduringstorage,particularlyFactorsV
andVIII,unlessstoredat30Corcolder.
Dilutionofcoagulationfactorsandplateletswilloccurfollowingadministrationoflargevolumes
ofreplacementfluids.Massiveorlargevolumetransfusionscanthereforeresultindisordersof
coagulation.

MassiveTransfusionProtocol

A massive transfusion protocol (MTP) should be used in critically bleeding patients anticipated to
require massive transfusion. The parameters in Table 6 below should be measured early and
frequently(every3060minutes,oraftertransfusionofbloodcomponent).

Table6:Parametersinmassivetransfusioninvestigationandmonitoring
Parameter
Valuesforwhichtoaim
Temperature
>35C
Acidbasestatus
pH>7.2,baseexcess<6,lactate<4mmol/L
Ionisedcalcium(Ca)
>1.1mmol/L
Haemoglobin(Hb)
Thisshouldnotbeusedaloneasatransfusiontrigger;and,shouldbe
interpretedincontextwithhaemodynamicstatus,organandtissue
perfusion
Platelets(Plt)
50x109/L
PT/APTT(activatedpartial
1.5xofnormal
thromboplastintime)
Fibrinogen
1.0g/L

Mortality is high in massive transfusion and its aetiology is multifactorial, which includes
hypotension, acidosis, coagulopathy, shock and the underlying condition of the patient. The lethal
triad,i.e.patientswithacidosis,hypothermia,andcoagulopathyhavethehighestmortalityrate.Itis
often the underlying cause and consequences of major haemorrhage that result in complications,
rather than the transfusion itself. However, administering large volumes of blood and intravenous
fluidsmayitselfgiverisetothefollowingcomplications.
34

Acidosis

Acidosisinapatientreceivingalargevolumetransfusionismorelikelytobetheresultofinadequate
treatmentofhypovolaemiathanduetotheeffectsoftransfusion.Undernormalcircumstances,the
bodycanreadilyneutralizethisacidloadfromtransfusion.Theroutineuseofbicarbonateorother
alkalizingagents,basedonthenumberofunitstransfused,isunnecessary.

Hyperkalaemia

Thestorageofbloodresultsinasmallincreaseinextracellularpotassiumconcentration,whichwill
increase the longer it is stored. This rise is rarely of clinical significance, other than in neonatal
exchangetransfusions.Freshblood(upto7daysold)shouldberequestedfromthebloodcentre.

Citratetoxicityandhypocalcaemia

Citratetoxicityisrare,butismostlikelytooccurduringthecourseofalargevolumetransfusionof
wholeblood.Hypocalcaemia,particularlyincombinationwithhypothermiaandacidosis,cancausea
reduction in cardiac output, bradycardia, and other dysrhythmias. Citrate is usually rapidly
metabolized to bicarbonate. It is therefore unnecessary to attempt to neutralize the acid load of
transfusion.Thereisverylittlecitrateinredcellconcentrates.

Management

IfthereisprolongationofPT,giveABOcompatiblefreshfrozenplasmainadoseof15mL/kg.
IftheAPTTisalsoprolonged,FactorVIII/fibrinogenconcentrateisrecommendedinadditionto
FFP. If none is available, give 1015 units of ABO compatible cryoprecipitate, which contains
FactorVIIIandfibrinogen.
GivePCsonlywhen:
The patient shows clinical signs of microvascular bleeding: i.e. bleeding and oozing from
mucousmembranes,wounds,rawsurfacesandcathetersites.
Thepatientsplateletcountfallsbelow50x109/L.
GivesufficientPCstostopmicrovascularbleedingandmaintainanadequateplateletcount.
ConsiderPCtransfusionincaseswheretheplateletcountfallsbelow20x109/L,evenifthereis
noclinicalevidenceofbleeding,becausethereisadangerofoccultbleeding,suchasintobrain
tissue.

Theprophylacticuseofplateletconcentratesinpatientsreceivinglargevolumebloodtransfusionsis
notrecommended.

35

TransfusioninPaediatrics

PaediatricanaemiaisdefinedasareductionofHbconcentrationorredcellbloodvolumebelowthe
normalvaluesforhealthychildren.NormalHb/Hctvaluesdifferaccordingtotheageofthechild.

IndicationsforTransfusion

Hb4g/dLorHct12%.
Hb46g/dL(orHct1318%)ifanyoffollowingclinicalfeaturesarepresent:
Clinicalfeaturesofhypoxia.
Acidosis(usuallycausesdyspnoea).
Impairedconsciousness.
Hyperparasitaemia(>20%malarialparasites).

TransfusionofNeonatesandInfants

Thefollowingrecommendationsapplytothetransfusionofchildreninthefirstfourmonthsoflife:

Pretransfusiontesting:

Maternalsamples: ABOandRhDgroup

Antibodyscreen(5mLclottedblood)

Infantsamples:

ABOandRhDgroup
Directantiglobulintest(DAT)
Antibodyscreenifmaternalsampleunavailable(12mLclottedblood)

If thematernal antibody screen isnegativeandthe infantsred cellsareDATnegative,cross

matchingisunnecessaryandbloodofthebabysgroupcanbeissued.Alloantibodiesarerare
inthefirstfourmonthsoflifeandarerelatedtorepeatedmassivetransfusionsandtotheuse
offreshblood.

Ifthematernalantibodyscreenand/ortheneonatalDATarepositive,serologicalinvestigation
andfullcompatibilitytestingwillbenecessary.

After the first four months of life, cross matching procedures should conform to the require
mentsforolderchildren/adults.

9.1 Topuptransfusion

Topup transfusions are carried out in order to raise Hb concentration in symptomatic chronic
anaemia,oftenduetobloodsamplinginsickprematureinfants.

Limitdonorexposurewheneverpossible:ifrepeatedtransfusionsarelikelythennotifytheblood
transfusiondepartmentsothatsatellitebags(40mLeach)canbearranged.
PRBC (Hct 0.550.75) should be used for topup transfusions. Red cells in optimal additive
solutions,e.g.SAGMorCPDbloodcanbesafelyusedfortopuptransfusioninthisagegroup.
Completetransfusionwithin4hours.Transfusionratesof5mL/kg/houraresafe:increaserateif
activehaemorrhageandreduceifcardiacfailureexists.
Duetothesmallvolumeofbloodtobetransfused,itisacceptabletoflushthegivingsetwithan
appropriatefluid,e.g.isotonic(normal)salinetoextractthefullvolumeofredcells.
36

9.2 Exchangetransfusion

The main indication for neonatal exchange transfusion is to prevent neurological complications
(kernicterus)causedbyarapidlyrisingunconjugatedbilirubinconcentration.Optionforbloodgroup
isasfollows:

UsegroupObloodthatdoesnotcarrytheantigentowhichthematernalantibodyisdirected.
ForHDNduetoantiDusegroupORhDnegativeblood.
UsebloodoftheABOgroupoftheneonateoruseanalternativegroupwhichiscompatiblewith
maternalABOantibodies,andalsoABOcompatiblewiththeinfant.Otherwise,usedesignated
groupORhcompatibleunits.
Usebloodcompatiblewithanymaternalirregularantibodies.
Storageageofbloodshouldbewithinfivedaysofcollection.

When carrying out an exchange transfusion use whole blood for the first exchange followed by
plasmareducedblood(Hct0.550.60)forthesecondexchange.Thisistheonlyindicationfortheuse
ofwholeblood.

Useabloodwarmer.Onlyapprovedandregularlymonitoredbloodwarmingequipmentshould
be used: fatal transfusion reactions have followed the use of inappropriate blood warming
procedures.

TransfusionProcedure

Iftransfusionisneeded,givesufficientbloodtomakethechildclinicallystable.
5mL/kgofredcellsor10mL/kgwholebloodareusuallysufficienttorelieveacuteshortageof
oxygencarryingcapacity.ThiswillincreaseHbconcentrationby approximately23g/dLunless
thereiscontinuedbleedingorhaemolysis.
Aredcelltransfusion ispreferabletowholeblood forapatientatriskofcirculatoryoverload,
which may precipitate or worsen cardiac failure. 5 mL/kg of red cells gives the same oxygen
carrying capacity as 10 mL/kg of whole blood and contains less plasma protein and fluid to
overloadthecirculation.
Where possible, use a paediatric blood pack and a device to control the rate and volume of
transfusion.
Althoughrapidfluidinfusionincreasestheriskofvolumeoverloadandcardiacfailure,givethe
first 5 mL/kg of red cells to relieve the acute signs of tissue hypoxia. Subsequent transfusion
shouldbegivenslowly:e.g.5mL/kgofredcellsover1hour.
Give frusemide 1 mg/kg by mouth or 0.5 mg/kg by slow IV injection to a maximum dose of
20mg/kgifthepatientislikelytodevelopcardiacfailureandpulmonaryoedema.Donotinject
itintothebloodpack.
Monitorduringtransfusionforsignsof:
Cardiacfailure
Fever
Respiratorydistress
Tachypnoea
Hypotension
Acutetransfusionreaction
Shock
Haemolysis(jaundice,hepatosplenomegaly)
BleedingduetoDIC
ReevaluatethepatientsHborHctandclinicalconditionaftertransfusion.
37

If the patient is still anaemic with clinical signs of hypoxia or a critically low Hb level, give a
secondtransfusionof510mL/kgofredcellsor1015mL/kgofwholeblood.
Continuetreatmentofanaemia,suchaswithiron,tohelphaematologicalrecovery.

Ifexchangetransfusionisneeded:

Anexchangetransfusionofabouttwotimestheneonatesbloodvolume(about170mL/kg)is
mosteffectivetoreducebilirubinandrestoreHblevel;thiscanusuallybecarriedoutwithone
unitofwholeblood.

A unit of whole blood will normally have an Hct of 3745%, which is more than adequate for
neonatalneeds.

Whenexchangetransfusionisperformedtotreathaemolyticdiseaseofthenewborn(HDN),the
transfusedredcellsmustbecompatiblewiththemothersserumsincethehaemolysisiscaused
bymaternalIgGantibodiesthatcrosstheplacentaanddestroythefetalredcells.

Thebloodshouldthereforebecrossmatchedagainstthemothersserumusingtheantiglobulin
methodthatdetectsIgGantibodies.

9.3 Haemolyticdiseaseofthenewborn

HDN is caused by antibodies that are produced by the mother. These antibodies are IgG and can
crosstheplacentaanddestroythefetalredcells.Themothermaydeveloptheseantibodies:

Iffetalredbloodcellscrosstheplacenta(fetomaternalhaemorrhage)duringpregnancyordelivery.
Asaresultofapreviousredcelltransfusion.

HDNduetoABOincompatibilitybetweenmotherandinfantdoesnotaffectthefetusinutero,butis
animportantcauseofneonataljaundice.

HDNduetoRhDincompatibilityisanimportantcauseofseverefetalanaemiaincountrieswherea
significantproportionofthepopulationisRhDnegative.RhDnegativemothersdevelopantibodies
toanRhDpositivefetus,especiallywhenthemotherandinfantareofthesameorcompatibleABO
bloodtype.Thefetalredcellsarehaemolysed,causingsevereanaemia.

InthemostseverecasesofHDN:

Thefetusmaydieinutero.
Thefetusmaybebornwithsevereanaemiathatrequiresreplacementofredcellsbyexchange
transfusion.
There may also be severe neurological damage after birth as a result of a high bilirubin level
unlessthisiscorrectedbyexchangetransfusion.

HDN due to other blood group antibodies can also occur, in particular antic (also within the Rh
bloodgroupsystem)andantiKell.

Screeninginpregnancy

TheABOandRhDgroupofallpregnantwomenshouldbedeterminedwhentheyfirstattenda
clinicforantenatalcare.ThemothersbloodshouldalsobetestedforanyIgGredcellantibodies
thatcancauseHDN.

38

If no antibodies are detected at the first antenatal visit, the pregnant woman should have a
furtherantibodycheckat2830weeksgestation.

Ifantibodiesaredetectedatthefirstantenatalvisit,thelevelsshouldbemonitoredfrequently
throughoutthepregnancyincasetheyincrease.RisinglevelsarelikelytobeindicativeofHDN
developinginthefetus.

AntiRhDimmunoglobulin

AntiRhDimmunoglobulinpreventsthesensitizationandproductionofantibodiesinanunsensitised
RhDnegativemotherifRhDpositiveredcellsgainentryintohercirculation,eitherduringpregnancy
orduringdelivery.

9.4 ABOhaemolyticdiseaseofthenewborn

ThediagnosisofABOHDNisusuallymadeininfantsbornattermwhoarenotseverelyanaemic,
butwhodevelopjaundiceduringthefirst24hoursoflife.
ABOincompatibilitydoesnotpresentinuteroanddoesnotcausehydrops.
The neonate should receive phototherapy and supportive treatment; treatment should be
initiatedpromptlyasjaundicecanbecomesevereenoughtoleadtokernicterus.
BloodunitsforexchangetransfusionshouldbegroupOwithlowtitreantiAandantiB.
Atwovolumeexchange(approximately170mL/kg)ismosteffectiveinremovingbilirubin.
Ifbilirubinrisesagaintodangerouslevels,afurthertwovolumeexchangeshouldbeperformed.

9.5 TransfusionofplateletsandFFPinpaediatricpatients

Platelettransfusion

Platelettransfusionsareindicatedinneonatesandyounginfantswithacountbelow50x109/L
whoareexperiencingbleeding.
Dose:510mlPC/kgbodyweightwillincreasecountby50x109/Lto100x109/L.

TransfusionofFFP

Dose:1015mL/kgincoagulopathycondition.

Paediatric blood bags are available for blood transfusion of the infant patient. It should be
remembered that once a blood bag unit has been opened for transfusion it should be completed.
Partialtransfusionofasinglebagoversuccessivedaysisnotpermittedduetotheriskofinfection.

Figures4,5and6onthefollowingpages,provideexamplesofacrossmatchreportform,aformfor
makingtransfusionnotesandaformformakingnotesonthemanagementofadversetransfusion
reaction,respectively.

39

Figure4:Crossmatchreportform

40

Figure5:Transfusionnotes
PatientID
PatientName
Diagnosis
BedNumber

BloodGroup

Date
Age

PretransfusionHb

g/dL Date

SourceofBlood

Bagnumber

CollectionDate

Typeofcomponent

Crossmatchand
ScreeningLabID

Amountofblood

Sex

Ward

Transfusionstarttime
Pre
transfusion
Pulse

BP

Temperature

Respiration

Colourofurine
Droprate/min
Parameter

15minutes 30minutes

1hour

2hours

3hours

4hours

Timetransfusion
completed:
Transfusionwassuccessfulwithoutanyadversereaction
Completionof
transfusionnote Transfusionwasdeferredduetoadversereactionofseverecategory
(checkanswer) Transfusionwascompletedwithmanagementoffebrile/allergicreaction

Signatureofdoctor

41

Figure6:Managementofadversetransfusionreaction:physiciansnotes

ChiefComplaint/Concern:

OnExamination:
BP
RespiratoryRatePulse
Signofbleeding

Investigation:
Bloodsamples:bloodbag,patient
Urine,culture,electrolytes
BT,CT,APTT,bilirubin,directantiglobulintest

Reportofbloodtransfusioncentre

Treatment:

InstructionofExperts:(transfusionspecialist/
Anaesthetic/Departmentalhead)
SignatureofDoctor

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10 BloodTransfusionServicesinBangladesh
Toimprovethesafetyofbloodtransfusion,fromtheyear2000thegovernmentdevelopedfacilities,
in medical college hospitals, institutes, combined military hospitals, specialized hospitals, district
hospitalsandattheUpazilahealthcomplex.Thestrengtheningofbloodtransfusioncentresstarted
under the Safe Blood Transfusion Programme of the Ministry of Health and Family Welfare
(MOHFW). A legislative framework, the Safe Blood Transfusion Act, 2002 was enacted by the
Government.Bloodtransfusion centressupplybloodaftertesting formarkers to fiveTTIsi.e.HIV,
HepatitisB,HepatitisC,syphilisandmalaria,therequirementofwhichhasbeenmademandatoryin
accordancewiththeSafeBloodTransfusionLawinthecountry.

NationalSafeBloodTransfusionCouncil

This isa policymaking forumforbloodtransfusionservicesundertheMOHFWfordevelopingthe

policyasperdirectivesoftheSafeBloodLaw/Actforimprovementofbloodtransfusionservices.The
honourableHealthMinister,byposition,isthePresidentandDirectorGeneralofHealthServicesand
istheMemberSecretaryoftheCouncil.Directorsofinstitutes,andtheheadofthedepartmentof
bloodtransfusion,aremembersofthiscouncil.

NationalSafeBloodTransfusionExpertCommittee

TheNationalSafeBloodTransfusionExpertCommitteeisanimplementingbodyforthepolicyand
decision making by the National Safe Blood Transfusion Council, headed by the Director General
DGHSunderMOHFW.Itconsistsoftransfusionspecialistsasmembers,andtheDirectorGeneralis
thepresidentofthecommittee.

LocalHospitaltransfusionCommittee

Eachhospitalhasalocalbloodtransfusioncommitteewhichisconstitutedwithparticipationofthe
headofthedepartmentofalldisciplinesinthehospital.

StatutoryRegulationOrder

ThegovernmenthasformulatedrulesforthemanagementofbloodcentreswhichisknownasSRO
145.

43