Blood transfusion

5. introduction
•BLOODTRANSFUSIONISDEFINEDASTHEPROCESSOF
RECEIVINGBLOODPRODUCTSINTOONE’SCIRCULATION
INTRAVENOUSLY.THISISUSUALLYDONEASALIFESAVING
MANEUVERTOREPLACEBLOODCELLSORBLOODPRODUCTS
LOSTTHROUGHSEVEREBLEEDING,DURINGSURGERYWHEN
SEVEREBLOODLOSSOCCURSORTOINCREASETHEBLOOD
COUNTINANANAEMICPATIENT.
•TRANSFUSIONSUSUALLYINVOLVETHEUSEOFTWOSOURCESOF
BLOOD–ONE’SOWN(AUTOLOGOUSTRANSFUSION)OR
SOMEONEELSE’S(ALLOGENICTRANSFUSION).
•BLOODTRANSFUSIONSINVOLVESTHEUSEOFWHOLEBLOOD,
REDBLOODCELLS,WHITEBLOODCELLS,PLASMA,CLOTTING
FACTORSANDPLATELETS.

7. Blood and blood products
•BLOODISCOLLECTEDFROMDONORSWHOHAVEBEENPREVIOUSLY
SCREENEDTOEXCLUDEANYBLOODORBLOODPRODUCTSTHATMAY
HAVETHEPOTENTIALTOHARMTHEPATIENT.
•EACHUNITOFBLOODISTESTEDFOREVIDENCEOFHEPATITIS-B,
HEPATITIS-C,HUMANIMMUNODEFICIENCYVIRUSI&IIAND
SYPHILIS.
•THEABOANDRHESUSDBLOODGROUPISDETERMINEDASWELLAS
THEPRESENCEOFIRREGULARREDCELLANTIBODIES.
•THEBLOODISTHENPROCESSEDINTOSUB-COMPONENTS.

9. WHOLE BLOOD
•WHOLEBLOODISUNSEPARATEDBLOODCONTAININGAN
ANTICOAGULANT–PRESERVATIVESOLUTION.
ONEUNITOFWHOLEBLOODCONTAINS-
•450mlOFDONORBLOOD.
•50mlOFANTICOAGULANT-PRESERVATIVESOLUTION.
•HAEMOGLOBINapprox.12g/ml&HAEMATOCRIT35%-45%.
•NOFUNCTIONALPLATELETS.
•SINCEITISNOTSTERILIZED,CAPABLEOFTRANSMITTINGANYAGENT
PRESENTINCELLSORPLASMAWHICHHASNOTBEENDETECTEDBY
ROUTINESCREENING.
•HOWEVER WHOLE BLOODTRANSFUSIONHASSIGNIFICANT
ADVANTAGESOVERPACKEDCELLSASITISCOAGULATIONFACTORRICH
ANDIFFRESH,MOREMETABOLICALLYACTIVETHANSTOREDBLOOD.

10. •STOREDBETWEEN+2AND+6DEGREESCENTIGRATEINABLOOD
BANKREFRIGERATOR.
•TRANSFUSIONSHOULDBESTARTEDWITHIN30MINUTESOF
REMOVALFROMTHEREFRIGERATORANDCOMPLETEDWITHIN4
HOURSOFCOMMENCEMENT BECAUSECHANGESINTHE
COMPOSITIONMAYOCCURDUETOREDCELLMETABOLISM.
INDICATIONS–
•REDCELLREPLACEMENTINACUTEBLOODLOSSWITH
HYPOVOLAEMIA
•EXCHANGETRANSFUSION
CONTRAINDICATIONS–
•CHRONICANAEMIA
•INCIPIENTCARDIACFAILURE

12. PACKED RED CELLS
•PACKEDREDCELLSARECELLSTHATARESPUNDOWNAND
CONCENTRATED.
•ONEUNITOFPACKEDREDCELLSISAPPROX.330mlANDHASA
HAEMATOCRITOF50-70%.
•THEYARESTOREDINASAG-M(SALINE-ADENINE-GLUCOSE-
MANNITOL)SOLUTIONTOINCREASETHEIRSHELFLIFETO5WEEKS
AT2-6DEGREESCENTIGRATE.
•ITCARRIESTHESAMEINFECTIONRISKASINWHOLEBLOOD.
•INDICATEDINREPLACEMENTOFREDCELLSINANAEMICPATIENTS
ANDALSOUSEDWITHCRYSTALLOIDANDCOLLOIDSOLUTIONSIN
ACUTEBLOODLOSSCONDITIONS.

14. FRESH FROZEN PLASMA
•FRESHFROZENPLASMAISRICHINCOAGULATIONFACTORS.
•ITISSEPARATEDFROMWHOLEBLOODANDSTOREDAT-40TO-50
DEGREESCENTIGRATEWITHA2YEARSHELF-LIFE.
•ITISTHEFIRSTLINETHERAPYINTHETREATMENTOF
COAGULOPATHICHAEMORRHAGE.
•ALSOUSEDINTHEREPLACEMENTOFMULTIPLECOAGULATION
FACTORDEFICIENCIESLIKELIVERDISEASE,WARFARINOVERDOSE,
DEPLETIONOFCOAGULATIONFACTORSINPATIENTSRECEIVING
LARGEVOLUMETRANSFUSIONS,DISSEMINATEDINTRAVASULAR
COAGULATIONANDTHROMBOTICTHROMBOCYTOPENICPURPURA.

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

16. Platelets
•PLATELETSARESUPPLIEDASAPOOLEDPLATELETCONCENTRATE
CONTAININGABOUT250X109CELLSPERLITRE.
•PLATELETSARESTOREDONASPECIALAGITATORANDHAVEASHELF
LIFEOFONLY5DAYS.
•AREUSUALLYGIVENTOPATIENTSWITHTHROMBOCYTOPENIAOR
THOSEWITHPLATELETDYSFUNCTIONWHOAREBLEEDINGOR
UNDERGOINGSURGERYANDINPATIENTSWITHBONEMARROW
FAILURE.
•NOTINDICATEDIN–
•PATIENTSWITHITP,TTP,UNTREATEDDICANDINCASESOF
HYPERSPLENISM.

17. •DOSAGE–1UNITOFPLATELETCONCENTRATE/10kgBODYWEIGHT.
•4-6DONORUNITSOFPLATELETCONCENTRATESWILLRAISETHE
PLATELETCOUNTBY20-40X109/L.INCREMENTWILLBELESSIFTHERE
ISASSOCIATEDSEPTICEMIA,DIC,SPLENOMEGALY.
•COMPLICATIONS–
FEBRILEANDALLERGICURTICARIALREACTIONSARECOMMON
ESPECIALLYINPATIENTSRECEIVINGMULTIPLETRANSFUSIONS.
•PATIENTSONASPIRINTHERAPYRARLELYPOSEAPROBLEMBUT
THOSEPATIENTSONCLOPIDOGRELWHOAREACTIVELYBLEEDINGAND
UNDERGOINGMAJORSURGERYMUSTBEGIVENACONTINUOUS
INFUSIONDURINGTHECOURSEOFTHEPROCEDURE.

19. 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 gmsFIBRINOGEN IN 200-500 ml
RAISES THE FIBRINOGEN LEVEL BY APPROX. 1g/L.
•MUST BE INFUSED WITHIN 6 HOURS.

21. 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’.

22. •THEREFORE,BLOODGROUP‘O’ISCONSIDEREDASTHEUNIVERSAL
DONORASITHASNOANTIGENSTOPROVOKEAREACTIONAND‘AB’
BLOODTYPEISCONSIDEREDASTHEUNIVERSALRECIPIENTSAS
THEYHAVENOCIRCULATINGANTIBODIESTOTHEM.
•RHESUSSYSTEM-THERHESUSDANTIGENISSTRONGLYANTIGENIC
ANDISPRESENTINAPPROXIMATELY85%OFTHEPOPULATION.
ANTIBODIESTOTHE‘D’ANTIGENARENATURALLYNOTPRESENTIN
THEREMAINING15%OFTHEINDIVIDUALSBUTTHEIRFORMATION
MAYBESTIMULATEDBYTHETRANSFUSIONOFRH’+’REDCELLSOR
THEYMAYBEACQUIREDDURINGDELIVERYOFARH-D-POSITIVE
BABYLEADINGTOHAEMOLYTICDISEASEOFTHENEWBORNINA
SUBSEQUENTPREGNANCY.

23. MAKING THE
DECISION FOR
BLOOD
TRANSFUSION

24. •IFUSEDCORRECTLY,BLOODTRANSFUSIONCANBELIFE-SAVING,
INAPPROPRIATEUSECANENDANGERLIFE.
•THEDECISIONTOTRANSFUSEBLOODORBLOODPRODUCTS
SHOULDALWAYSBEBASEDONACAREFULASSESSMENTOFCLINICAL
ANDLABORATORYINDICATIONSTHATTRANFUSIONISNECESSARY
TOSAVELIFEORPREVENTSIGNIFICANTMORBIDITY.

25. minimisingthe need for blood
transfusion
•Preoperativeplanning-
•Historyandexaminationincludingsurgicalorbleedinghistory
•Fullbloodcount,bloodchemistry,coagulation,
•Considerautologousblooddeposit
•Considererythropoietintoboosthaemoglobinconcentration
•Treatironorfolatedeficiency
•Stopaspirinprophylaxisifpossible
•Dayofadmission
•Checkiftakingaspirin,non-steroidalanti-inflammatorydrugs,
anticoagulants
•Repeatfullbloodcount
•Considerdrugstoreducebleeding(suchasaprotinin)

26. Duringsurgery
•Bepreparedforlongerdurationtosecurehaemostasis
•Considerhypotensivesurgeryifappropriate
•Avoidhypothermia—giveallfluidsthroughawarmer
•Considerfibringluesandsealants
Postoperativecare
•Acceptlowerpostoperativehaemoglobinconcentration
•Accepttransfusionsofjustoneunitofblood,toexceedtransfusion
trigger
•Usecontinuousfacemaskoxygenifpatienthaslowhaemoglobin
concentration
•Prescribeironandfolicacidroutinely
•ConsiderTranexamicacid

28. •EXTERNALBLEEDING&MEDICALCONDITIONSLIKETHALASSEMIA.
•INTERNALBLEEDING–Eg.VARICEALBLEEDING,ECTOPICPREGNANCY,
ANTEPARTUMHAEMORRHAGE,RUPTUREDUTERUS,
TRAUMATICINJURIESTOTHECHEST,SPLEEN,PELVIS,LUNGS,REDCELL
DESTRUCTIONASINMALARIA,SEPSIS,DISSEMINATEDINTRAVASCULAR
COAGULATION.
•CARDIORESPIRATORYSTATEANDTISSUEOXYGENATION–BP,PULSE,
RESPIRATORYRATE,CAPILLARYREFILLTIME,PERIPHERALPULSES,
TEMPERATURE,URINEOUTPUT,CARDIACFAILURE.
•ASSESSMENTOFANAEMIA–CLINICALLYFROMTHETONGUE,PALMS,
EYES,NAILSANDFROMLABORATORYASSESSMENTOFTHEHAEMOGLOBIN
LEVELORHAEMATOCRIT.
•ANTICIPATEDSURGERYWHEREPOST-OPERATIVEBLOODLOSSISHIGHLY
PROBABLE,CONTINUOUSBLEEDINGORLIKELIHOODOFRECURRENCEOF
BLEEDING,CONTINUINGHAEMOLYSIS.

29. 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.

30. PERI-OPERATIVE RED BLOOD CELL
TRANSFUSION CRITERIA
HAEMOGLOBIN
LEVELg/dl
INDICATION
<6 Probably will benefit
from transfusion
6-8 Transfusion unlikely to be
of benefit in the absence
of bleeding or impending
surgery
>8 No indication for
transfusion

31. Who Transfusion guidelines for chronic
anaemia during pregnancy
DURATIONOF PREGNANCYHAEMOGLOBINLEVEL CONSIDERIF-
<36 WEEKS 5.0 g/dlor LESS EVEN
WITHOUT CLINICAL SIGNS
OF CARDIAC FAILURE OR
HYPOXIA
Hb5.0-7.0g/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/dlOR LESS Hb6.0 –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
andavailable.
Elective CS Planned +
Historyof APH, PPH,
Previous CS.

32. ESTIMATING BLOOD LOSS
•INORDERTOMAINTAINBLOODVOLUMEACCURATELY,ITIS
ESSENTIALTOCONTINUALLYASSESSSURGICALBLOODLOSS
THROUGHOUTTHEPROCEDURE.
BLOOD VOLUME
NEONATES 85-90ml/kgBody Weight
CHILDREN 80ml/kg Body Weight
ADULTS 70ml/kg Body Weight
Example: An adult weighing 60 kgswould 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 ungraduateddrains or suction bottles and subtract
their empty weight.

33. 4.Estimatebloodlossintosurgicaldrapes,togetherwiththat
poolingbeneaththepatientandontothefloor.
5.Notethevolumeofanyirrigationorwashoutfluidsthatare
usedduringsurgery.Subtractthisvolumefromthemeasured
bloodlosstoarriveatafinalestimate.
•INPOST-OPERATIVETRANSFUSIONCASES,THEHAEMOGLOBIN
LEVEL,URINEOUTPUT,BLOODPRESSURE,PULSERATE,HEART
RATE,CAPILLARYREFILLTIME,COLOUROFMUCOUS
MEMBRANES,RESPIRATORYRATEANDSYMPTOMSANDSIGNS
OFHYPOXIASHOULDBECAREFULLYMONITORED.

34. WHO ACCEPTABLE BLOOD LOSS GUIDELINE
METHOD HEALTHY PATIENTAVERAGECLINICAL
CONDITION
POOR CLINICAL
CONDITION
PERCENTAGE
METHOD –
Acceptable loss of
blood volume
30% 20% <10%
HAEMODILUTION
METHOD –Lowest
acceptable
Haemoglobinor
Haematocrit
9g/dl or
Haematocrit
= 27%
10g/dl or
Haematocrit
= 30%
11g/dl or
Haematocrit
=33%
Duringsurgery,howeverthedecisiontotransfusewillultimately
needtobebasedonthecarefulassessmentofVolumeofblood
loss,Rateofbloodloss,Patient’sclinicalresponsetobloodloss
andfluidreplacementtherapy&signsindicatinginadequatetissue
oxygenation.

35. SAFE
BLOOD
TRANSFUSION
PROCEDURES

36. •EVERYHOSPITALSHOULDHAVEWRITTENSTANDARDOPERATING
PROCEDURESFORTHEADMINISTRATIONOFBLOODPRODUCTSLIKE
THEONEWEHAVEINOURHOSPITAL,PARTICULARLYFORTHEFINAL
IDENTITYCHECKOFTHEPATIENT,THECOMPATIBILITYLABEL
DETERMININGTHEPATIENT’SABOANDRH-DGROUP,UNIQUE
DONATIONNUMBEROFTHEBLOODPACK,BLOODGROUPOFTHE
BLOODPACK,THEDATEOFCOLLECTIONANDTHEEXPIRYDATE,THE
INDICATIONFORTRANSFUSION,SIGNATUREOFTHECLINICIAN
PERFORMINGTHEPRE-TRANSFUSIONIDENTITYCHECKANDTHE
TRANSDUSIONPROCEDURE
•THEBLOODPACKSHOULDALWAYSBEINSPECTEDFORSIGNSOF
DETERIORATIONONARRIVALANDBEFORETRANSFUSIONIFNOTUSED
IMMEDIATELY.
•DISCOLOURATIONOFTHEBLOODPACKANDANYSIGNSOFLEAKAGE
INDICATECONTAMINATIONANDCOULDCAUSEASEVEREFATAL
REACTIONIFTRANSFUSED.

37. DISPOSABLE EQUIPMENT FOR BLOOD ADMINISTRATION
•CANNULASMUSTBESTERILEANDMUSTNEVERBEREUSED.
•FLEXIBLEPLASTICCANNULASSHOULDBEUSEDASTHEYARESAFER
ANDPRESERVETHEVEINS.
FOR WHOLE BLOOD, RED CELLS, PLASMA & CRYOPRECIPITATE
•USEANEWSTERILEBLOODADMINISTRATIONSETCONTAININGAN
INTEGRAL170-200micronFILTER
•CHANGETHESETATLEAST12HOURLYDURINGBLOODCOMPONENT
INFUSION.
•INAWARMCLIMATE,CHANGETHESETMOREFREQUENTLYAND
USUALLYAFTEREVERY4UNITSOFBLOODIFGIVENWITHINA12
HOURPERIOD.

38. •THEREISNOEVIDENCETHATWARMINGBLOODISBENEFICIALTO
THEPATIENTWHENINFUSIONISSLOW.ATINFUSIONRATES
>100ml/minute,COLDBLOODMAYBEACONTRIBUTINGFACTOR
INCARDIACARREST.HOWEVER,KEEPINGTHEPATIENTWARMIS
PROBABLYMOREIMPORTANTTHANWARMINGTHEINFUSED
BLOOD!
•WARMEDBLOODISMOSTCOMMONLYREQUIREDINLARGE
VOLUMERAPIDTRANSFUSIONS&EXCHANGETRANSFUSIONIN
INFANTS.
•BLOODSHOULDONLYBEWARMEDINABLOODWARMERTHAT
HAVEAVISIBLETHERMOMETERANDANAUDIBLEWARNING
ALARMANDSHOULDBEPROPERLYMAINTAINED.

39. INTRAVENOUSCANNULATIONSFORBLOODTRANSFUSIONCANBE
DONEFROM–
•CEPHALICVEIN
•BASILICVEIN
•FOREARMVEINS
•GREATSAPHENOUSVEINS

41. MONITORING THE TRANSFUSED PATIENT
1.FOREACHUNITOFBLOODTRANSFUSED,MONITORTHE
PATIENT:
•BEFORESTARTINGTHETRANSFUSION
•15MINUTESAFTERSTARTINGTHETRANSFUSION
•ATLEASTEVERYHOURDURINGTRANSFUSION
•ONCOMPLETIONOFTHETRANSFUSION
•4HOURSAFTERCOMPLETINGTHETRANSFUSION
2.ATEACHOFTHESESTAGES,RECORD:
•PATIENT’SGENERALAPPEARANCE
•BLOODPRESSURE,PULSE,RESPIRATORYRATE
•FLUIDBALANCE–ORALANDIVFLUIDINTAKE&URINARY
OUTPUT.

42. 3.RECORD:
•TIMEWHENTHETRANSFUSIONISSTARTED.
•TIMEWHENTHETRANSFUSIONINCOMPLETED.
•VOLUMEANDTYPEOFALLPRODUCTSTRANSFUSED.
•BLOODPACKNUMBERS.
•ANYADVERSEEFFECTS.
SEVEREREACTIONSMOSTCOMMONLYPRESENTINTHEFIRST15-30
MINUTESOFATRANSFUSIONTHEREFORETHEYSHOULDBE
CLOSELYMONITOREDDURINGTHISTIME.
IFTHEPATIENTAPPEARSTOBEEXPERIENCINGANADVERSE
REACTIONTHETRANSFUSIONMUSTBEIMMEDIATELYSTOPPED
ANDURGENTMEDICALASSISTANCESHOULDBESEEKEDFOR.

43. REFERENCES:
•thewhohandbookontheclinicaluseofblood–who
bloodtransfusionsafety,geneva,2007.
•bailey&love’sshortpracticeofsurgery–25
th
edition–
2008.
•davidson’sprinciple&practiceofmedicine–21
st
edition–
2010.
•essentialpaediatrics–o.p.ghai–6
th
edition.
•onlinetextfromthebritishmedicaljournal–
www.bmj.co.uk/bloodtransfusionsafety 31781/o3.