Blood transfusion and its implication

blood loss and its consequences

1. BLOOD TRANSFUSION AND
ITS CLINICAL IMPLICATION
DR ZIKRULLAH

2. History of
Blood Transfusion
•1616-William Harvey discovered that
blood has a flow inside the animal body.
•.1667-The first recorded blood transfusion
into vein or arterytook place in France and
was unsuccessful.
•1668-The Pope banned any kind of
experiment on blood.

3. •1818-Dr. James Blunded was successful in saving a man’s life
•by direct transfusion from another man.
•1874-William Highmore first suggested autologous
•transfusion.
•1875-Karl Landsteiner was first to notice that just any man’s
•blood cannot be transfused to another.
•1900-01-Karl Landsteiner’s experiment revealed A, B and O
•group in human blood. Karl Landsteiner was awarded “Nobel Prize”
•for his grand discovery.

4. •1914-18-Blood transfusion was used during the first world war,
•1937-World’s first hospital blood bank was established on
•March 15, in Cook County Hospital of Chicago, U.S.A.
•1939-India’s first blood bank was set up in the School of
•Tropical Medicine, Kolkatta (Calcutta) by Sir
•Upendranath Brahmachari, the then Chairman of Bengal
•Red Cross Society.
•1940-Rhesus Factor of Blood was discovered

5. •1941-Blood collecting bottles and also the collection quantity
•per unit was specified.
•1957-Dr. Gibson found out the process of storing blood upto 28 days in a
temperature of 4 -6°C by mixing it up with a solution of ACD and sodium
dihydrogen phosphate.
•1964--Infection of jaundice through blood transfusion was
•confirmed.
•1986-First AIDS patient due to blood transfusion in Mumbai
•was reported.

6. •1996-Supreme Court’s judgment on blood transfusion and
•blood banking in India; as a result of which National
•Blood Transfusion Council and State Blood Transfusion
•Councils were established for improvement of Blood
•Banking services in the country.
•2000-World Health Day on 7th April 2000 was celebrated
•with, “Safe blood starts with me” as the slogan of the
•year.

7. Some Mathematics in Blood
Banking
•??????Human body contains 4-5 liters of Blood, or about 8%
ofBody Weight.
•??????40-45% of Blood is made up of red blood cells which
carry oxygen. The remaining 55-60% is plasma with a
small proportion of white blood cells for defending the
body,clotting factors and platelets preventing the blood
leak.
•??????The average person has 25 billion red blood cells.

8. •??????After each donation of blood it takes 36 hours for the body
•to reconstitute the blood volume and 21 days for the blood
•count to return to a normal level.
•??????Upto 7% HIV Infection in India is due to transfusion of
•blood and blood products. Transmission of HIV infection
•by infected blood transfusion is almost 100% effective in
•each case.
•??????One can donate blood 168 times in his lifetime, which
•measures to 58 litres of blood i. e. 12 times the
•total blood volume of the body.

9. Screening test for donors blood prior to
transfusion
•Infection screening
•VDRL
•HbsAg
•Anti HIV
•Anti HCV
•Malarial parasite
•Grouping and reverse grouping
•Cross matching

10. Storage of blood
•Series of changes occur in vitrothat alters
the physiological properties
•To ensure that blood retains its in vivo
environment involves
•Anticoagulants
•Preservative
•Characteristics of plastic bag
•Storage temperature
•Shipping and transport conditions

11. Red cell anticoagulants and
preservation
•Citrate
•Calcium-chelating agent
•Prevents coagulation by interfering with calcium-dependent steps
in the coagulation cascade
•Citrate-dextrose
•The dextrose provide nutrient for red cells
•Support the generation of ATP by glycolysis thus enhancing red
cell viability and extending shelf life
•Acid-citrate-dextrose
•Contains citric acid, sodium citrate, and dextrose
•Shelf life of 21 days and now no longer use for red cells as other
solution are available with extended shelf life of red cells
•Acid pH does not help in maintaining 2,3-DPG levels
•Used in apheresis procedure

12. Red cell anticoagulants and
preservation
•Citrate-phosphate-dextrose (CPD)
•Alkaline pH helps in maintaining 2,3-DPG
•Shelf life is extended to 28 days
•CPD is not now commonly used
•Citrate-phosphate-dextrose-adenine (CPDA-1)
•Addition of adenine is associated with improved synthesis
of ATP, allowing longer shelf life (35 days)
•Other solutions
•Adsol or AS-1
•Nutricel or AS-3
•Optiso or AS-5

13. Red cell anticoagulants and
preservation
•Saline-adenine-glucose-mannitol (SAGM)
•After taking blood donation in CPD and separating red
cells from plasma and platelets SAGM is added to the
packed red cells
•The resulting red cells have flow characteristics
equivalent to plasma reduced blood and a storage life of
35-42 days
•Other advantage is by removing maximum amount of
plasma from blood for the manufacture of factor VIII
and albumin

14. Storage changes in blood
•In vivo,red cells are carried and protected by
the plasma, which helps
•Regulated temperature
•Controlled pH
•Adequate glucose supply
•Removal of metabolic waste
–In protected environment life span is 110-120 days
–Lowering of temperature and preservatives do help
in reducing the changes but changes do occur and
known as “storage lesion”

15. Storage changes in blood
•pH
•Glycolysis is slowed at temperature of 1 to 6
0
C
•Glycolysis results in the production of lactate and
decrease in pH
»Day 0 (CPD) pH = 7.20
»Day 21 (CPD) pH = 6.84
•ATP
•ATP is closely associated with red cell viability
•Loss results in rigidity and decrease deformability
•ATP is also needed for Na
+
/K
+
-ATPase pump
•ATP levels on day 35 of storage is 45% in CPDA-1

16. Storage changes in blood
•2,3-DPG levels
•Decrease in pH of stored blood results in low 2,3-DPG
levels
•With low levels there will be left shift of oxygen
dissociation curve and increase affinity of oxygen
•After transfusion the levels return to normal values
within 24 hours
•Na
+
and K
+
levels
•Na
+
/K
+
leak through the red cells
•Cells lose potassium and gain sodium
•Plasma Hemoglobin
•Hemolysis results in raised plasma Hb

17. Appropriate storage temperatures
•WB and packed RBC1 to 6
0
C
•FFP ≤ -18
0
C
•Platelets 20 to 24
0
C
•Cryoprecipitate ≤ -18
0
C

18. DEFINITIONS
•Blood product -Any therapeutic substance prepared from human blood
•Whole blood -Unseparated blood collected into an approved container
•containing an anticoagulant-preservative solution
•Blood component -1-A constituent of blood, separated from whole blood,
•such as:
• Red cell concentrate
• Red cell suspension
• Plasma
• Platelet concentrates
2-Plasma or platelets collected by apheresis*
3-Cryoprecipitate, prepared from fresh frozen plasma,
•which is rich in Factor VIII and fibrinogen

19. WHO principles for the clinical
use of blood components
•1. Transfusion is only one element of the patient’s management.
•2. Prescribing decisions should be based on the national guidelines on the
clinical use of blood components, taking individual patient needs into account.
•3. Blood loss should be minimised to reduce the patient’s need for transfusion.
•4. The patient with acute blood loss should receive effective resuscitation
(intravenous replacement fluids, oxygen etc) while the need for transfusion is
being assessed.
•5. The patient’s haemoglobin level, although important, should not be the sole
deciding factor in starting transfusion. The decision to transfuse should be
supported by the need to relieve clinical signs and symptoms and prevent
significant morbidity and mortality

20. •6. The clinician should be aware of the risks of transfusion-
transmissible infection in the blood components that are available for
the individual patient.*
•7. Transfusion should be prescribed only when the benefits to the
patient are likely to outweigh the risks.
•8. The clinician should record the reason for transfusion clearly.
•9. A trained person should monitor the transfused patient and respond
immediately if any adverse effects occur.

21. WHOLE BLOOD
•Whole blood contains 450 ±45 ml or 350 ±
35 ml of donor blood plus anticoagulant
solution.
•Haemoglobin approximately 12 g/ml
•Haematocrit 35 (45%)
•No functional platelets
•No labile coagulation factors (V and VIII)

22. •Infection risk-Not sterilized, so is capable of transmitting
any agent present in cells or plasmawhich has not been
detected by routine screening for transfusion-transmissible
•infections, including:
• Hepatitis B and C
• Other hepatitis viruses
• HIV-1 and HIV-2
• Syphilis
• Malaria
• Chagas disease

23. •STORAGE-Between +2°C and +6°C in an approved blood bank
refrigerator, ideally fittedwith a temperature chart and alarm.
•May be stored up to 35 days if collected in a suitable anticoagulant
such ascitrate phosphate dextrose with added adenine (CPDA-1)
During storage at +2°C to +6°C, changes in composition occur
resulting from red cell metabolism .
•INDICATIONS -Red cell replacement in acute blood loss with
hypovolaemia
• -Exchange transfusion
• -Patients needing red cell transfusions where red cell
concentrates or suspensions are not available

24. •Contraindications -Risk of volume overload
in patients with:
• -Chronic anaemia
• -Incipient cardiac failure
•Administration -Must be ABO and Rh
compatible with the recipient

25. RED CELL CONCENTRATE
•May also be called ‘packed red cells’, ‘concentrated red
cells’ or ‘plasma-reduced blood’.
•Description -150–200 ml red cells from which most of the
plasma has been removed
•Haemoglobin approximately 20 g/100 ml (not less than 45
g per unit)
•Haematocrit 55–75%
•Infection risk-Same as whole blood
•Storage-Same as whole blood

26. Packed Red Cells
•Indications
•Surgery -• Patient need urgent operation and has Hb <
10g/dl
•• Anticipated surgical blood loss > 1000 ml
•Loss of blood - Replacement Fluid
•< 20% of blood vol. - None
•20-30% of blood vol. -Crystalloids/Colloids
•30-40% of blood vol. -RBCs & crystalloids
•> 40% of blood vol. Whole blood or RBCs &
Crystalloids

27. Others
• Anemia associated with incipient/established
cardiac failure
•• Hb value < 6 g/dl
•• Patients approaching delivery and has Hb
value < 7 g/dl
•• In hereditary hemolytic anemias and beta
thalassaemia major.

28. Guidelines for Pediatric RBC Transfusions
Children and Adolescents
•Acute loss >25% circulating blood volume
•Hgb < 8.0 g/dL in perioperative period
•Hgb < 13.0 g/dL and severe cardiopulmonary
disease
•Hgb < 8.0 g/dL and symptomatic chronic anemia
•Hgb < 8.0 g/dL and marrow failure

29. Infants within First 4 months of Life
•Hgb < 13.0 g/dL and severe pulmonary disease
•Hgb < 10.0 g/dL and moderate pulmonary disease
•Hgb < 13.0 g/dL and severe cardiac disease
•Hgb < 10.0 g/dL and major surgery
•Hgb < 8.0 g/dL and symptomatic anemia

30. Advantages of transfusion of red
cells
•• Reduce risk of circulatory overload due to less
volume of anticoagulant and plasma
•• Lessens severity and incidence of allergic
reactions
•• ABO antibodies are reduced, red cells non-ABO
identical to patient’s group can be given,if
compatible.
•• Removed plasma can be used for preparing FFP
and cryoprocipitate (factors VIII and V)

31. Contraindications of transfusion
of red cells
•• Well compensated anemic patients such as chronic renal failure.
•• Nutritional anemia such as iron deficiency or pernicious anemia responsive
to iron, folic acid, recombinant erythropoietin etc. unless patient shows signs
of decompensation.
•• To correct protein and coagulation factors deficiency
•• Preoperative transfusion to raise Hb above 10 g/dl
•• To enhance general well being, promote wound healing, prevent infection,
expand blood volume when oxygen-carrying capacity is adequate.

32. LEUKOCYTESREDUCED
REDBLOOD CELLS
•Leukocytes-reduced red blood cells are indicated in the following
conditions:
•• Multitransfused patients like thalassaemic
•• Leukemia
•• Aplastic anemia
•• Immunosupressed
•• Immunodeficient
•• Multiparous women
•• Prevention of recurrent FNHTRs
•• Prevention or delay of primary alloimmunization to HLA antigen
•• Prevention of CMV transmission in at risk individual

33. WASHED RED CELLS
•Washing of red cells removes 70 -95 % of leukocytes and there is
concomitant loss of 15 -20 ml of red blood cells, but it is effective in
removal of plasma proteins and microaggregates.
•Indications
•• Patients having recurrent attacks FNHTRs and urticarial reactions.
•• Patients who have developed antibodies to plasma proteins.
•• IgA deficient patient who has developed anti-IgA •
•Paraoxymal noctural hemglobiuria (PNH), sensitive to complement

34. FROZEN/DEGLYCEROLIZED
RED CELLS
•Indications
•• The provision of rare blood lacking common
antigens for patients with corresponding
antibodies.
•• Autologous units of patients with multiple red
cells alloantibodies stored for future surgery.
•• IgA deficient patient with antibodies to IgA

35. PLATELET CONCENTRATES
(prepared from whole blood
donations)
•DESCRIPTION-Single donor unit in a volume of 50–60
ml of plasma should contain:
• At least 55 x 109 platelets
• <1.2 x 109 red cells
• <0.12 x 109 leucocytes
•Single donor unit: platelets prepared from one donation
•Pooled unit: platelets prepared from 4 to 6 donor units
‘pooled’ into one pack to contain an adult dose of at least
240 x 109 platelets

36. •INFECTION RISK -Same as whole blood, but a normal
adult dose involves between 4 and 6 donor exposures
•Bacterial contamination affects about 1% of pooled units
•STORAGE -20°C–24°C (with agitation) for up to 5 days
in specialized platelet packs,
•although some centres use ordinary plastic packs which
restrict storage to 72 hours.
•Longer storage increases the risk of bacterial proliferation
and septicaemia in the recipient.

37. Indications
•Treatment of bleeding due to:
•—Thrombocytopenia
•—Platelet function defects
•Prevention of bleeding due to
thrombocytopenia, such as in bone marrow
failure.

38. Platelet Transfusions
Guidelines for Pediatric Platelet
Transfusions
Children and Adolescents
•PLTs < 50 x 10 9/L and bleeding
•PLTs < 50 x 10 9/L and invasive procedure
•PLTs < 20 x 10 9/L and marrow failure with hemorrhagic
risk factors
•PLTs < 10 x 10 9/L and marrow failure without
hemorrhagic risk factors
•PLTs at any count, but with PLT dysfunction plus
bleeding or invasive procedure

39. Infants within 1st 4 months of life
•PLTs < 100 x 10 9/L and bleeding
•PlTs < 50 x 10 9/L and invasive procedure
•PLTs <20 x 10 9/L and clinically stable
•PLTs < 100 x 10 9/L and clinically unstable
•PLTs at any count, but with PLT dysfunction plus
bleeding or invasive procedure

40. •Goal: Raise platelet count > 50 x 10 9/L
(up to 30 kg infusing 10 ml/Kg), maximum
of 6 pooled whole blood-derived platelet
units or 1 apheresis unit , as fast drip.

41. Contraindications
•Not generally indicated for prophylaxis of bleeding in
surgical patients, unless
•known to have significant pre-operative platelet deficiency
•Not indicated in:
•—Idiopathic autoimmune thrombocytopenic purpura
(ITP)
•—Thrombotic thrombocytopenic purpura (TTP)
•—Untreated disseminated intravascular coagulation (DIC)
•—Thrombocytopenia associated with septicaemia, until
treatment has
•commenced or in cases of hypersplenism

42. Dosage
•1 unit of platelet concentrate/10 kg body
weight: in a 60 or 70 kg adult, 4–6
•single donor units containing at least 240 x
109 platelets should raise the platelet count
by 20–40 x 109/L
•

43. Administration
•After pooling, platelet concentrates should be infused as
soon as possible,
•generally within 4 hours, because of the risk of bacterial
proliferation
•Must not be refrigerated before infusion as this reduces
platelet function
•4–6 units of platelet concentrates (which may be supplied
pooled) should be
•infused through a fresh standard blood administration set
•Special platelet infusion sets are not required

44. •Platelet concentrates should be infused over about 30
minutes
•Platelet concentrates prepared from Rh D positive donors
should not be given
•to a Rh D negative potential child-bearing female
•Platelet concentrates that are ABO compatible should be
given whenever possible.
•COMPLICATIONS -Febrile non-haemolytic and allergic
urticarial reactions are not uncommon,especially in
patients receiving multiple transfusions.

45. PLATELET CONCENTRATES
(collected by plateletpheresis)
•Description Volume 150–300 ml
•Platelet content 150–500 x 109, equivalent to 3–
10 single donations
•Platelet content, volume of plasma and leucocyte
contamination depend on the
•collection procedure
•Infection risk-Same as whole blood
•Storage Up to 24 hours at 20°C–24°C (with
agitation) unless collected using a blood cold

46. •INDICATION-Platelet concentrates collected by apheresis are,
generally, equivalent to thesame dose of platelet concentrates prepared
from whole blood.
•If a specially typed, compatible donor is required for the patient,
several doses may be obtained from the selected donor.
•DOSAGE -1 pack of platelet concentrate collected from a single donor
by apheresis is usually equivalent to 1 therapeutic dose.
•ADMINISTRATION -Same as for recovered donor platelets, but ABO
compatibility is more important:
•high titre counts of A or B in the donor plasma used to suspend the
platelets may cause haemolysis of recipient’s red cells.

47. FRESH FROZEN PLASMA
•DESCRIPTION -Pack containing the plasma separated
from one whole blood donation within 6 hours of
collection and then rapidly frozen to –25°C or colder.
•Contains normal plasma levels of stable clotting factors,
albumin and immunoglobulin.
•Factor VIII level at least 70% of normal fresh plasma level
•Unit of issue -Usual volume of pack is 200–300 ml
•

48. •STORAGE-At –25°C or colder for up to 1 year
•INDICATIONS -Replacement of multiple coagulation
factor deficiencies, e.g.:
• —Liver disease
• —Warfarin anticoagulant overdose
•—Depletion of coagulation factors in patients receiving
large volume transfusions.
•Disseminated intravascular coagulation (DIC)
•Thrombotic thrombocytopenic purpura (TTP)
•DOSAGE-Initial dose of 15 ml/kg

49. Fresh Frozen Plasma
Transfusions
Guidelines for Pediatric FFP Transfusions
Infants , Children , Adolescent
•Severe clotting factor deficiency and bleeding
•Severe clotting factor deficiency and invasive procedure
•Emergency reversal of warfarin effects
•Dilutional coagulopathy and bleeding
•Anticoagulation protein (AT -III, protein C and S)
replacement
•Plasma exchange replacement fluid to thrombotic
thrombocytopenia

50. •Transfused to replace clinically significant
deficiencies of plasma proteins for which
more highly purified concentrates are not
available.
•dose: 15ml/kg

51. Indications for FFP in neonates
1. reconstitution of RBC concentrates to simulate whole
blood for use in massive transfusions (exchange
transfusion or cardiovascular surgery)
2. hemorrhage secondary to vitamin K deficiency
3. disseminated intravascular coagulation with bleeding
4. bleeding in congenital coagulation factor deficiency
when more specific treatment is either unavailable or
inappropriate.

52. •The use of prophylactic FFP transfusions to
prevent intraventricular hemorrhage in
premature infant is not recommended.
•The use of FFP in neonatal hyperviscosity
syndrome is unnecessary because safer
colloid solutions are available.

53. Administration
•Must normally be ABO compatible to avoid risk of haemolysis in
recipient
•No crossmatching needed
•Before use, should be thawed in water which is between 30°C and
37°C.
•Higher temperatures will destroy clotting factors and proteins
•Once thawed, should be stored in a refrigerator at 2°C–6°C
•Infuse using a standard blood infusion set as soon as possible after
thawing
•Labile coagulation factors rapidly degrade; use within 6 hours of
thawing

54. Precautions
•Acute allergic reactions, especially with
rapid infusions
•Severe life-threatening anaphylactic
reactions occasionally occur.
•

55. CRYOPRECIPITATE
•Description -Prepared from fresh frozen plasma
by collecting the precipitate formed during
•controlled thawing and resuspending it in 10–20
ml plasma
•Contains about half of the Factor VIII and
fibrinogen in the donated whole blood: e.g. Factor
VIII: 80–100 i.u./pack; fibrinogen: 150–300
mg/pack
•Unit of issue-Usually supplied as a single donor
pack or a pack of 6 or more single donor units

56. •Infection risk -As for plasma, but a normal adult dose
involves at least 6 donor exposures
•Storage -At –25°C or colder for up to 1 year
•Indications -As an alternative to Factor VIII concentrate in
the treatment of inherited deficiencies of:
•—Von Willebrand Factor (von Willebrand’s disease)
•—Factor VIII (haemophilia A)
•—Factor XIII
•As a source of fibrinogen in acquired coagulopathies: e.g.
disseminated intravascular coagulation (DIC)

57. •Administration -If possible, use ABO-
compatible product
•No compatibility testing is needed
•After thawing, infuse as soon as possible
through a standard blood administration set
•Must be infused within 6 hours of thawing

58. Strategy for Safe Blood
Transfusion
•:
•.
•100% Voluntary, nonremunerated blood donation.
•Stringent donor recruitment with risk related questionnaire.
•Self exclusion or self deferral.
•??????Rational use of blood and blood products.
•Promoting use of plasma expanders as blood substitutes.
•??????Screening of blood units mainly for HIV 1 -2, HB V, HCV,
•syphilis and Malaria, with inclusion of screening tests
•for infections prevalent in particular geographical region.
•??????Use of recombinant factor VIII, F-VII in bleeding
•disorders.
•??????Autologous blood Transfusion.

59. BLOOD TRANSFUSION
•1. Ordering Blood:
•a. Safe transfusion practice begins with correct identification
•of the intended recipient.
•b. Blood samples of the recipient are to be collected, identified
•and labeled properly.
•c. Blood samples are to be sent to the blood bank for grouping
•and cross-matching.
•d. Blood transfusion request must provide all the relevant
•data in the requisition form.

60. •.
. ABO Group, Rh type, crossmatching of
recipients blood is to be carried out..
•i. In case of any discrepancy a fresh blood
sample is to be sent to the blood bank for
grouping-crossmatching.

61. Steps to be taken in the blood
bank at the
time of the issue of blood:
•A) Identification of intended recipient:
•??????Blood request form.
•??????Compatibility form.
•??????Transfusion form

62. Steps to be taken by the
transfusionist at
the time of transfusion:
•B. Check all the identifying information,
•Identity of the recipient on the transfusion form;
•Check ABO group, Rh type.
•Check the sero negativity label against TTI.
•Donor unit identification number is checked.
•Expiry date is confirmed.
•Check the compatibility label or tie tags.
•Transfusionist must start transfusion against physicians
•“WRITTEN ORDERS” after following the above steps.

63. •THE UNIT SHOULD NOT BE TRANSFUSED IF
•The unit has been (or may have been) out of the
refrigerator
• for longer than 30 minutes
• or
• If there is any sign that there is a leak or the
bag has been opened
• or
• The plasma is pink or red
• or
• The red cells look purple or black

64. •Since blood is an excellent culture media, keeping the blood bag at
•room temperature for longer duration could result in
•bacterial overgrowth.
•. In case medical condition of recipient demands that
•transfusion is to be given slowly over a longer period, ask
•for split units of blood from the blood bank and give each
•unit over 4 hours.
•Rapid infusion may be necessary in certain clinical settings.
•In such conditions use MECHANICAL DEVICES for
•rapid transfusion. Blood pressure cuff is unsuitable for
•providing external pressure on the blood bag.

65. •Blood warming:
•-As blood flows drop by drop it attains body temperature
•quickly therefore warming of blood is NOT necessary for
•routine blood transfusion.
•-Blood warming results in increased metabolism, reduced
•2-3 DiphosphoGlycerate (DPG) and increases the risk of
•bacterial overgrowth.
•Indications for Blood warming are:
•Massive transfusion 100 ml/minute or 1 blood bag every
•3 minute in which case the recipient may develop
•hypothermia and arrhythmias.
•Exchange transfusion in a neonate.
•Cold agglutinin disease.

66. Few undesirable practices:
•1. Blood warming using water-bath.
•2. Delay in transfusion after issue from the blood bank.
•3. Use of unmonitored refrigerator for storage of blood and
•blood component, e. g. nursing station refrigerator.
•4. Rate and duration of the transfusion.
•5. Routine pretransfusion medication.
•6. Insertion of medication.
•7. Use of same transfusion set for more than one
•transfusion.

67. TIME LIMITS FOR INFUSION
Start infusionComplete
infusion
Whole blood/red
cells
Within 30
minutes
Within 4 hours
Platelet
concentrates
ImmediatelyWithin 20
minutes
Fresh frozen
plasma
Within 30
minutes
Within 20
minutes

68. MONITORING THE
TRANSFUSED PATIENT
•1 For each unit of blood transfused, monitor the patient at
the following
•stages:
•Before starting the transfusion
•As soon as the transfusion is started
•15 minutes after starting transfusion
•At least every hour during transfusion
•On completion of the transfusion
•4 hours after completing the transfusion

69. •At each of these stages, record the following information
on the patient’s
•chart:
•Patient’s general appearance
•Temperature
•Pulse
•Blood pressure
•Respiratory rate
•Fluid balance:
•—Oral and IV fluid intake
•—Urinary output.

70. •Record:
• Time the transfusion is started
• Time the transfusion is completed
• Volume and type of all products transfused
•Unique donation numbers of all products transfused
•Any adverse effects.
•Monitor the patient particularly carefully during the first
15min of the transfusion to detect early signs and
symptoms of adverse effects

71. Guidelines for the recognition of
transfusion reactions are :
Category 1 -Mild reaction
Sign Symptoms Possiblecause
??????Localized ??????-
Urticaria
-Rashes
Itching ?????? Hypersensitivity
(mild)

72. Category 2 -Moderately Severe
Sign Symptoms Possible cause
Urticaria Rigor
Fever
Restlessness
Tachycardia
Anxiety
Pruritus (itching)
Palpitations
Mild dyspnoea
Headache
Hypersensitivity
Febrile non-
haemolytic
transfusion
reations:-
Antibodies to
w.b.c,platelets

73. Category 3 -Life-Threatening
Sign Symptoms Possible Cause
Rigor
Fever
Restlesness
Hypotension(>2
0%fall in S.B.P)
Tachycardia(>20
%rise in H.R)
Haemoglobinuri
a
Anxiety
Chest pain
Respiratory
distress
Loin pain
Headache
dyspnoea
Acute
intravascular
haemolysis
Bacterial
contamination
and septic shock
Fluid overload
anaphylaxis
Transfusion
associated lung
inury

74. Management in Adverse
Transfusion Reactions
Category I: Mild
•1. Slow the transfusion.
•2. Administer antihistamine IM (e.g.
Chlorpheniramine 0.01 mg/kg or equivalent)
•3. If no clinical improvement within 30 minutes or
if signs and symptoms worsen, treat as
•Category 2.

75. Category 2: Moderately Severe.
•1. Stop the transfusion, replace the giving set and keep I.V. line open with normal saline.
•2. Notify the doctor responsible for the patient and blood bank immediately.
•3. Send blood unit with giving set, fresh blood samples (1 clotted and 1 in EDTA) from vein opposite infusion site
with appropriate reaction form to blood bank for investigations.
•4. Administer antihistamine IM (e.g. chlorpheniramine 0.01 mg/kg or equivalent) and oral or rectal antipyretic (eg.
paracetamole 10 mg/kg; 500 mg -lg in adults).
•5. Give I.V. corticosteroids and bronchodilators if there are anaphylactoid features (eg.
•broneospasm. stridor).
•6. Collect urine for next 24 hrs for evidence of haemolysis and sent to laboratory.
•7. In clinical imporvement, restart transfusion slowly with new blood unit if required and observe carefully.

76. Category : 3 Life-threatening
•1. Stop the transfusion, replace the giving -set and keep I.V. line open with
normal saline.
•2. Infuse normal saline (initially 20-30 ml/kg) to maintain systolic BP.
•3. Maintain airway and give high flow oxygen by mask.
•4. Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by
intramuscular injection in severe allergic reaction.
•5. Give I.V. corticosteroids and bronchodilators if there are anaphylactoid
features (e.g.broncospasm, stridor)
•6. Give diuretic: e.g. frusemide 1 mg/kg I.V. or equivalent (initially 40 mgm
i.v., upto 250 mgm over 4 hours)

77. •7. Notify the doctor responsible for the patient and the blood bank
immediately.
•8. Send blood unit with giving-set, fresh blood samples (1 clotted and 1 in
EDTA) form vein
•opposite to the infusion site, with appropriate reaction form to blood bank for
investigation.
•9. Check a fresh urine specimen visually for signs of hemoglobinuria (red ro
pink urine).
•10. Start at 24 hour urine collection and fluid balance chart and record all
intake and output.
•Maintain fluid balance.
•11. Assess for bleeding form puncture sites or wounds. If there is clinical or
laboratory evidence
•of DIC, give platelets (adult 5-6 units) and either cryoprecipitate (adult 12
units) or fresh
•frozen plasma (adult: 3 units)

78. •12. Reassess. If hypotension persists: ■Give further saline 20-30
ml/kg.
•■Give Inotrope (Dopamine, IV infusion,}
13. If urine output falling or laboratory evidence of acute renal failure
(rising K+, urea,creatinine):
•■Maintain fluid balance accurately
•■Give further frusemide.
•■Consider dopamine infusion.
•■Seek expert help: the patient may need renal dialysis.
•13. If bacteraemia is suspected (rigors, fever, collapse, no evidence of
a haemolytic reaction), start broad spectrum antibiotics I.V. to cover
pseudomonas and gram positives organisms.

79. Delayed complications of
transfusion
•Delayed complications of transfusion essentially fall into two
categories.
•1>Transfusion-transmitted infections:
• HIV-1 and HIV-2
• HTLV-I and II
• Viral hepatitis B and C
• Syphilis
• Chagas disease
• Malaria
• Cytomegalovirus
•Other rare infections: e.g. human parvovirus B19 and hepatitis A

80. Other delayed complications of
transfusion
•Other delayed complications of transfusion which
occur days, months or even years after the
transfusion has been completed, include:
•Delayed haemolytic reaction
•Post-transfusion purpura
•Graft-vs-host disease
•Iron overload (in patients who receive repeated
transfusions)

81. MASSIVE BLOOD
TRANSFUSION
•• Massive blood transfusion is usually defined as the replacement of
one or more blood volume(s) within 24 hours.
•• Transfusion of about ten units of whole blood each of 450 ml of
blood or 20units of redcells, within 24 hours.
•• Replacement of more than 50% of the blood volume in 3 hours in an
adult..
•Normal blood volume usually being approximately :
•• In adult about 70 ml per kg body weight or 7% of the body weight
•• In children about 80 ml per kg. body weight or 8% of body weight
•• In neonates 85-90 ml per kg body weight or 8.5 -9.0% of body
weight.

82. Massive transfusion may be required
due to acute hemorrhage in :
•• Surgical or medical emergencies (e.g. gastro-
intestinal bleeding especially from varices.)
•• Cardiac and vascular surgery
•• Exchange transfusion in infants
•• Obstetric cases.
•• In multiple trauma
•• Liver transplant

83. Complications of massive or large
volume transfusion
•Acidosis
•Hyperkalaemia
•Citrate toxicity and hypocalcaemia
•Depletion of fibrinogen and coagulation factors
•Depletion of platelets
•Disseminated intravascular coagulation (DIC)
•Hypothermia
•Reduced 2,3 diphosphoglycerate (2,3 DPG)
•Microaggregates

84. TRANSFUSION IN SEVERE
(DECOMPENSATED) ANAEMIA
•1 Do not transfuse more than necessary..
•The aim is to give the patient sufficient haemoglobin to relieve hypoxia.
•The dose should be matched to the patient’s size and blood volume
•Patients with severe anaemia may precipitate into cardiac failure by
•infusion of blood or other fluids. If transfusion is necessary, give one
•unit, preferably of red cell concentrate, over 2 to 4 hours and give a
•rapid acting diuretic (e.g. frusemide, 40 mg)
•Reassess the patient and, if symptoms of severe anaemia persist, give a
•further 1–2 units.
•It is not necessary to restore the haemoglobin concentration to normal
•levels. Raise it enough to relieve the clinical condition

85. •Severe anaemia due to malaria is a significant cause of mortality in
children and is the commonest reason for paediatric transfusion in
many endemic areas.
ADULTS, including PREGNANT women:
• transfuse if haemoglobin <7 g/dl
•CHILDREN:
• Transfuse if haemoglobin <4 g/dl
• Transfuse if haemoglobin 4–6 g/dl and
• clinical features of:
• —Hypoxia
• —Acidosis
• —Impaired consciousness
• —Hyperparasitaemia (>20%)

86. TRANSFUSION IN BONE
MARROW SUPPRESSION
•Severe anaemia -Red cell transfusion
•Bleeding due to thrombocytopenia -Platelet transfusion
•If repeated transfusions are likely to be needed, it is
preferable to use leucocyte-reduced red cells and platelets,
wherever possible
•Chemotherapy, irradiation therapy and bone marrow
transplant further suppress bone marrow and increase the
need for platelet and red cell transfusion until remission
occurs

87. TRANSFUSION IN DIC
•1 If the PT or APTT is prolonged and the patient is bleeding:
•Replace red cell losses with the freshest whole blood available as it
•contains fibrinogen and most other coagulation factors
•and
•Give fresh frozen plasma as this contains labile coagulation factors:
•1 pack/15 kg body weight (4–5 packs in adults)
•Repeat FFP according to the clinical response.
•2 If fibrinogen is low or the APTT or thrombin time is prolonged, also give
•cryoprecipitate (to supply fibrinogen and Factor VIII): 1 pack/6 kg
•(8–10 packs in adults).
•3 If the platelet count is less than 50 x 109/L and the patient is bleeding,
•also give platelet concentrates: 4–6 packs (adult).

88. chronic anaemia of pregnancy
•DURATION OF PREGNANCY LESS THAN 36 WEEKS
•1 Haemoglobin 5.0 g/dl or below, even without clinical
signs of cardiac failure or hypoxia
•2 Haemoglobin between 5.0 and 7.0 g/dl and in the
presence of the following conditions:
•Established or incipient cardiac failure or clinical evidence
of hypoxia
•Pneumonia or any other serious bacterial infection
•Malaria
•Pre-existing heart disease, not causally related to the
anaemia

89. •DURATION OF PREGNANCY 36 WEEKS OR MORE
•1 Haemoglobin 6.0 g/dl or below
•2 Haemoglobin between 6.0 g/dl and 8.0 g/dl and in the
presence of the following conditions:
•Established or incipient cardiac failure or clinical evidence
of hypoxia
•Pneumonia or any other serious bacterial infection
•Malaria
•Pre-existing heart disease, not causally related to the
anaemia

90. •ELECTIVE CAESAREAN SECTION
•When elective Caesarean section is planned and there is a
history of:
•Antepartum haemorrhage (APH)
•Postpartum haemorrhage (PPH)
•Previous Caesarean section
•1 Haemoglobin between 8.0 and 10.0 g/dl:
establish/confirm blood group and save freshly taken
serum for crossmatching
•2 Haemoglobin less than 8.0 g/dl: two units of blood
should be crossmatched and available

91. estimating allowable blood
loss before transfusion
Method HealthyAverage
clinical
condition
Poor
clinical
condition
Percentage method
Acceptable loss of
blood volume
30% 20% Less than
10%
Haemodilution
method
Lowest acceptable
haemoglobin (or
Hct)
9 g/dl (Hct
27)
10 g/dl (Hct
30)
11 g/dl
(Hct 33)

92. ACUT E LY HA EMOR R HAG
ING PAT I ENT S
•In acutely haemorrhaging patients, early intervention can
reduce later problems.
•This may involve the use of one or more blood
components, depending on a range of factors. The first step
is to differentiate between ‘controlled’ bleeding, usually
•during surgery, and established massive bleeding, usually
associated with haemostatic failure, which is much more
difficult to treat. The following algorithm
•outlines some steps in the management of acutely
haemorrhaging patients.

94. AutologousBloodTransfusion
•Blood collected from a patient for re-transfusion at a later
time into the same individual is
•called "autologous blood". The patient who receives his or
her own blood gets the safest possible
•blood because no foreign antigens infused, no infectious
diseases other than the patient may
•already have are transmitted. Its use has increased with the
awareness of infections
•particularly human immuno-defficiency virus (HIV)
transmitted through allogenic (homologous)
•tranfusion

95. The general categories of
autologous transfusions are:
•(1) Preoperative donation of blood -2 or more units blood are drawn and
stored prior to anticipated need.
•(2) Intra-operative blood collection -blood is collected in operation theatre
prior to surgery or during surgery and include:
• a) Perioperative hemodilution -1 or 2 units of blood is drawn before
• (acute normo volemic hemodilution) surgery and concomitantly
replaced with crystalloid or colloid solution.
• b) Intraoperative blood -blood is collected (salvage) from the surgical
• field, then processed and returned.
(3) Post operative blood collection

96. Advantages
•• Prevents the possibility of transfusion-transmitted infections like HIV, HBsAg, HCV
and Treponema Pallidum (syphilis).
•• Prevents alloiminimization to red cells, leukocytes, platelets , and plasma proteins.
•• Supplements blood supply.
•• Prevents adverse transfusion reactions especially allergic and febrile reactions.
•• Provide blood to patients having antibodies against common antigens.
•• Provides blood to patients who refuse homologous blood transfusion because of
religious belief.
•• Preoperative autologous donation stimulates the bone marrow to increase cell
production.