Safe Blood Transfusion

Lecture By:
Dr Hisham Fakher
Consultant Hematology
Medical Director of Regional Laboratory and Central Blood Bank
Ministry of Health –Almadinah Almonawarah

2. Dr Hisham Fakher
Consultant Hematology
Medical Director of Regional Laboratory and
Central Blood Bank
Ministry of Health –Almadinah
Almonawarah

3. INTRODUCTION
Blood transfusion refers to a large range of therapeutic
products prepared in the blood bank from the whole
blood or manufactured from pooled human plasma by
selective procedures for the purpose of the clinical usage.
The blood products include whole blood, packed Red
Blood Cells, Fresh Frozen Plasma, Platelet Concentrates,
Cryoprecipitate, Granulocytes, Leucoreduced Products,
Irradiated Products and Plasma Derivatives.
Blood transfusion has become well regulated through
Guidelines by organizations such as American
Association of Blood Banks (AABB), Council of Europe
Health Institutions and Organization and World Health
Organization (WHO).

4. The departmental and interdepartmental policies and
procedures could be developed for :
•Requests for transfusion, collection of blood samples for pre-
transfusion compatibility testing.
•Collection of blood and blood components from the Blood
Bank and their delivery to the ward.
•The administration of blood and blood components
•Documentation of transfusions
•The care and monitoring of transfused patients
•The management and reporting of adverse events
•The specification of staff responsible for various tasks.

5. Does the patient need blood products.
What are the alternative options for treatment.
Using the product that will be most effective in
providing the desired outcome.
Minimum donor exposure.
Considerations for therapy
Include:

6. 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
•Plasma
•Platelet concentrates
2. Plasma or platelets collected by apheresis
3. Cryoprecipitate prepared from fresh frozen plasma

7. Request for Transfusion
1- Request for transfusion of blood/blood component is to be made by the
physician on a Blood Bank request form and should includes
(a) Patient Identification :-
Surname , First name , Date of birth ,
Hospital number / accident .
(b) Type of blood component or blood product
(c) Specify product requirements (e.g. CMV negative ,
irradiated etc.)
(d) Number of units and/or volume of product or apheresis
(e) Unmatched blood (in emergency or life- threatening
situations
2- Telephone orders are accepted in urgent situations but should be followed-
up with a standard request.

8. Component Preparation and
Selection

- Pre-transfusion compatibility testing must be performed for
whole blood and red cell components prior to issue to minimize
the risk of hemolytic transfusion reaction and maximize post-
transfusion red cell survival.
- The majority of ABO incompatible transfusion due to
documentation / identification error .
- Compatibility testing is not required for platelet and plasma
components. However, ABO and Rh blood groups of the
intended recipient must be known prior to component selection
for issue.
- Components issued for transfusion must have been tested
and found negative for markers of the following infective agents
: Hepatitis B and C, Syphilis, HTLV, HIV and malaria parasites.

9. Compatibility testing
Can be divided into 3 categories:
Preanalytical procedures
Serological testing
Postanalytical procedures

10. Pre-analytical phases
Patient identification
Specimen collection
Review of patient history

11. Patient Identification
Must confirm
recipient’s ID from
bracelet ON the
patient
Full patient name and
hospital number
Name of physician
http://www.usatoday.com/tech/news/techinnovations/2006-07-17-chips-everywhere_x.htm

12. Sample Identification
The sample should
also have the full
patient name, hospital
number, and physician
Date and time of
collection,
phlebotomist’s initials
All of this should be
on the request form
and the sample

13. Specimen Collection
Collected in tube with EDTA and no additives
If the venipuncture causes hemolysis, the sample
may be rejected
Samples are labeled at the bedside (pre-labeling is
not recommended)
A record of individuals who collect (or test) the
specimens should be documented in order to
“backtrack” in case of an error

14. Specimen Collection
If the sample is drawn from an IV line, the IV infusion
should be stopped 5-10 minutes prior to blood
drawing and the first 10 mL discarded
Testing should be performed on samples less than 72
hours .

15. Getting the history
Look at recipient’s records for any prior unexpected
antibodies
Previous transfusion reactions

16. Serological Testing
3 tests:
ABO/Rh
Antibody detection/identification
Crossmatch

17. Compatibility testing for
patients more than 4 month
old
ABO/Rh Typing
 In the ABO typing, the forward and reverse MUST
match
In the Rh typing, the control must be negative
Both of these will indicate what type of blood should
be given

18. Antibody screening
Antibody screening is valid for 72 hr if it is
negative and patient needs repeated transfusion ,
patient only need immediate spin crossmatch and
ABO /Rh typing .
Antibody screening valid for one week in patient
have no history of transfusion or pregnancy in the
last three months .

19. Antibody screen / Identification
The antibody screen will detect the presence of
any unexpected antibodies in patient serum
If antibodies are detected, identification should
be performed using panel cells (with an
autocontrol)
IS
37° (LISS)
AHG
If an antibody is present, units negative for the
antigen must be given after crossmaching.

20. Cross matching
Purpose:
Prevent transfusion reactions
Increase in vivo survival of red cells
Double checks for ABO errors
Another method of detecting antibodies
Steps foe crossmaching :-
1- IS
2- 37° (LISS)
3- AHG

21. Parent
Allele
A B O
A AA AB AO
B AB BB BO
O AO BO OO
Possible Blood group Genotypes

22. The ABO blood groups
• The most important in assuring a safe blood transfusion.
• The table shows the four ABO phenotypes ("blood groups")
present in the human population and the genotypes that give
rise to them.
Blood
Grou
p
Antigens
on RBCs
Antibodies in SerumGenotypes
A A Anti-B AA or AO
B B Anti-A BB or BO
AB A and B Neither AB
O Neither Anti-A and anti-B OO

23. Blood
Type
Genotype
Alleles
Produced
Rh positive
RR R
Rr R or r
Rh negative rr r
Rh Blood Group and Rh Incompatibility
A person with Rh- blood does not have Rh antibodies
naturally in the blood plasma

24. Selection of ABO Compatible Donor WB
Recipient 1st Choice
O Group O
A Group A Group
B Group B Group
AB Group AB Group

25. Selection of ABO Compatible Donor PRBCs
Recipient 1st Choice 2nd Choice 3rd Choice 4th Choice
O Group O Non Non Non
A Group A Group O Non Non
B Group B Group O Non Non
AB Group AB Group A Group B Group O

26. Suggested ABO Group Selection Order for Plasma ,
plasma cryoprecipitate
Recipient 1st Choice 2nd Choice 3rd Choice 4th Choice
O O AB A B
A A AB
B B AB
AB AB

27. Suggested ABO Group Selection Order for Platelets
ABO 1st Choice 2nd Choice 3rd Choice 4th Choice
O O AB A B
A A AB (B) (O)
B B AB (A) (O)
AB AB (A) (B) (O)

28. ABO Compatibility

29. Sample storage
18- 24c 4c -18c
EDTA whole
blood
Up to 48 hr Up to 7 days -----
Serum ----- Up to 7 days Up to 6 months

30. Post-analytical phase
Involves labeling, inspecting, and issuing the
blood unit
Labeling form includes patient’s full name, ID
number, ABO/Rh of patient and unit, donor #,
compatibility results, and tech ID
Form is attached to the donor unit and only
released for the recipient
The unit is visually inspected for abnormalities,
such as bacterial contamination, discoloration ,
haemolysis , leaking , clots .

31. Bacterial contamination
This unit shows
bacterial
contamination and
should NOT be given
to the patient
The plasma in the
segments is fine, but
the plasma in the unit
shows heavy hemolysis
from bacteria

32. Issuing blood
When it’s time to release a blood product to the nurse
or physician, a few “checks” must be done
Requisition form
Comparing requisition form  donor unit tag  blood
product label
Name of persons issuing and picking up blood
Date and time of release
Expiration date
Visual inspection for the units .

33. Delay in Starting Transfusion

•Should a delay in starting transfusion occurs, the nurse must
ensure return of the blood unit to the Blood Bank within 30
minutes of the collection.

•In the case of the theater which has a well-monitored blood
storage facility, whole blood, red cell component and FFP may be
stored in the storage facility, but not for more than 6 hrs .

•Platelet concentrate and thawed cryoprecipitate should not be
stored in the Ward or Theater fridge. Should delay in transfusion
more than 30 min occurs such units must be maintained at room
temperature.

36. LEAKS
DISCOLOURATIO
N
CLUMPING
EXPIRY DATE
If there is ANY discrepancy - DO NOT transfuse
Pre-administration Procedure
Step 3: Undertake visual inspection
Step 1: Check the blood component has been prescribed
Step 2: Undertake baseline observations

37. Step 1: Ask the patient to tell you their:
Full Name + Date of Birth
Check this information
against the patient’s ID
wristband

38. Step 2: Check the patient’s
–First name
–Surname
–Date of birth
–Hospital number
on the compatibility/
traceability label against
the patient’s ID wristband
Administration Procedure

39. Any discrepancies DO
NOT TRANSFUSE !
Administration Procedure
Step 3: Check the compatibility/traceability label with the
blood bag label

40. Starting transfusion
How do you transfer RBC unit?
23 gauge needle or larger (18 gauge preferred)
Starting transfusion should be slowly at rate of
2ml/min for the first 20-50- ml to check for reaction .
Run at 2-5 mL /min
Maximum time to transfuse 4 hours
Vital signs within 15 minutes of start

41. Starting Transfusion
 Sign the “Blood Transfusion Report that is attached to the product
and fill in the start time.
 Monitor the patient throughout the transfusion for signs of an
adverse reaction.
 Monitor infusion rates. Slower infusion rates may be necessary in
infants, the elderly or patients that are cardiovascularly compromised
or at risk for fluid overload .
 Patient vital signs must be checked and documented . It is
recommended that vital signs be monitored:-
- Within one hour prior to starting the transfusion .
- After the first 15 minutes of the transfusion .
- Every hour during the transfusion .
- One hour following completion of the transfusion .

42. Starting Transfusion
 Immediately document on the patient record at the time
of transfusion:
- The unit number.
- Type of blood component or blood product transfused.
- Date and time of start and finish.
- Identity of individual who administered the transfusion.
- If the patient experienced an adverse transfusion
reaction.

 If a product is still hanging at the end of four hours from
dispensing, discontinue and discard the remaining
product

43. Post administration
In the absence of a transfusion reaction .
- Disconnect the blood product and administration set.
- Flush IV line with normal saline or compatible solution following
transfusion.
- Remove the Blood Transfusion Report and complete the required
information.
- Document and/or place the chart copy in the appropriate location of
the patient’s chart.
- Return a copy of Blood Transfusion Report to blood transfusion
service (BTS) within 24 hours of the transfusion .
- Discard empty blood bags, bottles and tubing in the appropriate
blood/body fluid equipment container.

44. Action for Suspected Transfusion Reaction

ATTENDING NURSE should:
1- Switch off the transfusion immediately.
2- Maintain IV patency with appropriate IV solution (0.9 %
normal saline )
3- Reconfirm the identification of the donor unit, the
recipient and the attached crossmatch / issue label against
the information on the crossmatch report form. If there is
discrepancy, the nurse in-charge immediately notify the
patient’s physician and Blood Bank technologist, and
search other related records to ensure the error does not
affect other patient (s).
4- Check the vital signs every 15 minutes until patient is
stable .
5- Notify the patient’s physician

45. Action for Suspected Transfusion Reaction
ATTENDING PHYSICIAN should:
- Confirm the presence of transfusion reaction by
taking history and performing physical examination.
- Determine the probable type of transfusion
reaction and the action taken should be documented
on the patient chart .
- Notify the blood transfusion service .

46. Action for Suspected Transfusion Reaction
IF HAEMOLYTIC TRANSFUSION REACTION IS SUSPECTED
Inform the Hematologist or Blood Bank of the reaction.

Return the unit, the tubing and the attached label to the Blood Bank
with a completed request form for investigation of the transfusion
reaction.
Draw blood specimens for the following tests, when appropriate and
send to Blood Bank.

- 5-10 ml clotted sample if further crossmatch is needed.
- 5-10 ml clotted sample for transfusion reaction work-up.
- 2-5 ml purple top tube for CBC and DCT.
- Specimen of the first urine sample passed after the suspected
reaction for free Hb .

47. Documentation of transfusion
The following information is vital to document on
all transfusions:
Teaching performed to the patient/substitute
decision maker
Monitoring of the patient throughout the transfusion
How patient tolerated the transfusion
Presence or absence of a transfusion reaction
Date and time (start and finish) of transfusion

48. Potential Major Adverse
reaction of Blood Transfusion
•Acute and delayed haemolytic transfusion reactions
•Minor and major febrile reactions
•Minor and major allergic reactions
•Volume overload
•Transfusion related acute lung injury
•Viral infections (HIV, HBV, HCV, etc)

50. THE LIST OF MAXIMUM SURGICAL BLOOD USAGE

Procedure Blood Units
I- General Surgery
1- Breast biopsy .T / S.
2- Colon resection. 2
3- Laparotomy explorationT / S.
4- Gasterectomy.2
5- Mastectomy, radical.T / S.
6- Pancreatectomy 4
7- Splenectomy2
8- Thyroidectomy 2
9- Parathyroidectomy T / S.
10- Hasab operation 4
11- Hepatobiliary2
II- Vascular:
1- Aortic bypass graft4
2- Endarterectomy T / S.
3- Femoral – popliteal bypass graft2
III- Urology:
1- Trans urethral U.B resection or prostatectomy1
2- Radical Nephrectomy3
3- Radical perineal prostatectomy2
4- Renal Transplant 2
5- Radical cystectomy3

51. THE LIST OF MAXIMUM SURGICAL BLOOD USAGE

Procedure Blood Units
IV- OB-GYN:
1- Abdominal perineal repair or D.&.C.T / S
2- Emergency or Elective C/S2
3- Autepartum or post-partum hemorrhage 4
4- missd abortion 2
5- rupture uterus4
6- placenta previaT / S
7- myomectomy2
8- Simple abdominal or laparoscopic hystrectomy2
9- Radical hysterectomy4
10- Ectopic pregnancy 2
11- Cystectomy2
VI – Thoracic surgery:
1- Lung biopsy T / S
2- Lobectomy or bilopectory 2
3- Thoracotomy2
4- Thoracotomy with decortication 4
5- pneumonectomy 4
6- Rigid Thoracoscopy T / S
7- Oesophagectomy 4
8- pericardiectomy 2
9- Mediastinoscopy T / S

52. THE LIST OF MAXIMUM SURGICAL BLOOD USAGE

Procedure Blood Units
VII. Cardiac surgery:
1- Aneurism resection 6
2- Coronary bypass (Redo) 4
3- Coronary bypass (primary) 2
VIII. Plastic surgery:
1- Hemangioma 2
2- Cleft palate T / S
3- Pharyngioplasty T / S
4- Rhinoplasty and septoplsty 1
5- Abdominoplasty 2
6- Mamoplasty 2
7- Lipo suction 1-2
8- Bed sores 1-2
9- Burn 1-4
10- Head and neck 1-2
IX. Neurosurgery:
1- Craniectomy:
a- Extra or subdural Hematoma 2
b – Tumour excision 2
2- Lumbar dissectomy 1
3- Cervical dissectomy 1
4- Spinal tumour exicision 2

53. THE LIST OF MAXIMUM SURGICAL BLOOD USAGE

Procedure Blood Units
X. Orthopedic surgery:
1- Arthroscopy, laminectomy or knee replacements T / S
2- Cervical spine fusion and fixation 2
3- Thoraco lumbar spine fusion and fixation 2-4
4- Shoulder, Humerus or elbow surgery 2
5- Total Hip replacement 3-6
6- Austin moore 1
7- DHS 2-4
8- Femur shaft (plate or nail) 2-4
9- Tibia (plate or nail) 2
10- Debridment 2
11- Peodiatric CDH or Femur plating 1
XI. Dental Surgery:
1- Reduction , fixation , biopsy, or Cyst T / S
2- Coronidectomy 1
3- Condylectomy 2
4- Osteotomy 2
5- Genioplasty 1
6- Tumor Resection with reconstruction 4

55. Emergency Release
In an emergency (ER or OR), there may not be enough
time to test the recipient’s sample
In this case, blood is released only when signed by the
physician (O negative)
The tag must indicate it is not crossmatched
Segments should be retained for X-matching
Every detail is documented (names, dates..)

56. Emergency Release
Once the specimen is received, ABO/Rh typing and
antibody screening should be performed
Crossmatching the segments from the released unit
should be tested
In addition, the lab may crossmatch additional
units as a precaution if more blood is needed
If death should occur, testing should be complete
enough to show that the death was unrelated to an
incompatibility

57. What can be given in an emergency?
Group O Rh-negative red cells or AB plasma
Emergency release
Women below or of childbearing age
Or if in doubt
Group O Rh-positive red cells
Used as a substitution
Male or elderly females

58. Appropriate PRBCs units to give
Patient’s TypePatient’s Type11
stst
Choice Choice Other ChoicesOther Choices
OO OO NoneNone
AA AA OO
BB BB OO
ABAB ABAB A, B, OA, B, O
ABO compatible should always be given first
• Group O individuals are “universal donors”, they can donate to any blood
group because they have no A or B antigens
• Group AB individuals are “universal recipients”, they can receive blood
from any group because they do not have A or B antibodies

59. Massive transfusion
Defined as a transfusion approaching or
exceeding the recipient’s own blood volume
(about 5 liters or 10-12 units in an adult male)
within 24 hour period
The original sample no longer represents the
patient’s condition
Complete crossmatch not necessary (if no
antibodies were detected originally)
Give ABO identical units
If antibodies were originally ID’s, continue to give
antigen negative units

60. Type & Screen
Used to conserve blood inventory
On average, a surgical procedure uses about 1 unit
of RBCs, however, many times the units are on
“hold” in the lab an will not be needed (reducing
inventory)
For this reason, only a type & screen are
performed and if any blood is needed, the sample
can be retrieved for crossmatching (only the IS
phase is required)
If antibodies are identified, then antigen negative
blood is reserved or crossmatched

61. Exchange transfusion
Blood should be 5 days old or less
Packed RBCs constituted with plasma AB

62. Autologous crossmatching
Autologous refers to a donation from the recipient for
later use
Special procedures/protocols must be available so
that the autologous unit is found and transfused to
the recipient
Pretransfusion testing procedures vary

63. Other components
Other components to be given do not need to be
crossmatched because they have been thoroughly
screened for antibodies
Frozen plasma
Platelet concentrate
Cryoprecipitate
Platelets pheresis
Granulocyte concentrates
Give ABO compatible units

64. New Technologies…
The electronic crossmatch
According to the AABB, the following must be
fulfilled:
Critical elements of the information system have been
validated on-site.
No clinically significant antibodies are detected in the
current blood sample and there is no record of clinically
significant antibodies in the past

65. Computer crossmatch (cont’d)
The patient's ABO group and Rh type has been
done twice and entered in the computer
 The donor unit identification number,
component name, and ABO/Rh type must also be
confirmed entered in the computer
The computer system will alert the technologist
to ABO & Rh discrepancies between information
on the donor label and results of donor
confirmatory testing

66. THANK YOU