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Blood transfusion: indications, administration and adverse reactions

Blood transfusion: indications, administration and adverse reactions

EBM Guidelines
13.8.2014
Essentials
Tests before a blood transfusion
Red cell transfusion
Platelet transfusion
Plasma transfusion
Administration of a blood transfusion
Blood transfusion reactions, near miss incidents and
mistransfusion
Suspicion of a transfusion reaction and/or mistransfusion
Related resources

Essentials
Donated blood is not transfused to the recipient until it has been processed into red cell, platelet
and fresh frozen plasma components.
Red cells are transfused in anaemia to provide adequate oxygen delivery.
Fresh frozen plasma is transfused to replace coagulation factors if haemorrhage is caused by
the simultaneous deficiency of several coagulation factors.
Platelets, i.e. thrombocytes, are indicated for the management of haemorrhage or in
thrombocytopenia to promote haemostasis where either the number or functioning of platelets
is insufficient.
In primary care, the use of blood products is usually limited to the treatment of symptomatic
chronic anaemia when no alternative treatment is available. Platelet transfusions may also
occasionally be administered, for example to patients with haematological diseases.
Blood transfusions are administered at an increasing frequency at the patients home by a
qualified nurse. In such cases, the code of practice stipulated for blood transfusions must be
closely adhered to. Home blood transfusion is only recommended for patients who have received
previous problem-free transfusions in a hospital setting.

Tests before a blood transfusion

Essentials
Verification of the patients identity
Before a non-urgent transfusion, tests should be carried out in good time (14 weeks) before
the planned transfusion.
The staff should be well versed in the unit specific instructions regarding special cases, e.g.
transfusions in children.
Determining the ABO and RhD group
Always before a transfusion of red cells, platelets, plasma and white cells
Two samples collected by two different people at different times
The samples may be collected at the same time for emergency transfusions with two separate
persons identifying the patient.
If the patients blood group data is stored in an electronic patient record system, it may be
possible in the future to do the blood group determination using the blood sample collected for
compatibility testing (cross matching).
Antibody screen
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Always before a transfusion of red cells and white cells

Identification of the antibodies if the result is positive
Validity has no time limit, except if the patient has a history of pregnancy or transfusion within
the 4 weeks preceding the antibody screen or after the screen, in which case the validity
period is 5 days.
Compatibility testing (cross matching)
Always before a transfusion of red cells and white cells
Valid for 5 days
Some hospital districts employ an electronic system (Type and Screen) to carry out
compatibility testing.
Compatibility testing must always be done serologically if red cell antibodies have been
detected or the patient has received a bone marrow or liver transplant.

Red cell transfusion

Indications
Chronic or slowly developing anaemia
It is not possible to give a single haemoglobin (Hb) value as a trigger for red cell transfusion
since the requirement for a transfusion is based on anaemia symptoms, the patients age and
the underlying diseases.
Most patients will suffer uncomfortable symptoms from anaemia if the concentration of Hb falls
below 70 g/l; even a less significant fall in the Hb concentration may cause symptoms in
patients with heart or lung diseases.
Red cell transfusions are not routinely recommended for the correction of anaemia in patients
with malignant or serious chronic diseases, unless the correction of Hb concentration is
expected to significantly improve the patients condition or independence.
The management of fatigue syndrome in chronic anaemia often requires an Hb level of 90100
g/l.
One unit of red cells typically raises the Hb concentration in an adult by approximately 10 g/l;
1(2) units should be transfused at a time whilst monitoring response.
Non-urgent surgery
The blood group determination and antibody screen should be done in good time before the
surgical procedure.
The procedure can be carried out as planned, even if the tests would reveal factors that
affect the choice or availability of blood products.
Acute or massive haemorrhage
The replacement of blood loss in traumatic, surgical, obstetric or other haemorrhage often
necessitates, in addition to red cell transfusion, the substitution of platelets and coagulation
factors.
The decision to proceed with emergency or massive transfusion is the responsibility of the
treating physician.
Guidelines issued specifically for each hospital and speciality, as regards the samples and tests
required as well as blood products available, should be referred to.
National and local guidelines apply as to the volume replacement procedure to be followed in
major and emergency haemorrhage.

Selecting red cells for transfusion

Essentials
As a general rule, the red cell units to be transfused should be compatible with the recipients
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ABO and RhD groups.

Laboratory personnel will give advice as to the choice of suitable alternative products should
the supply of compatible blood products become exhausted.
The transfusion of ABO incompatible blood products may cause a life-threatening transfusion
reaction.
RhD negative recipients should not receive RhD positive red cells except in life-threatening
situations since the transfusion is likely to trigger the production of anti-D antibodies, which in
females of childbearing potential may lead to haemolytic disease of the foetus and newborn.
RhD negative red cells can safely be transfused to RhD positive patients; however, as RhD
negative red cells are usually in short supply their transfusion to RhD positive recipients is only
recommended in special situations, for example when suitable RhD positive red cells are not
available or RhD negative red cells are close to their expiry date.
For the same reason females of childbearing potential should receive Kell (K) negative red cells.
Phenotype matched red cells
Patients who have clinically significant red cell antibodies
must receive red cells that are negative to the blood group against which the patient has
antibodies
should also receive Kell negative red cells in order to avoid further immunisation.
If the patient has several antibodies or has a rare blood group, arrangements for transfusion
should be made well in advance and the blood components should be ordered several days
before the planned transfusion.
Washed red cells
For patients with a confirmed deficiency of immunoglobulin A (serum IgA < 0.05 mg/l) and antiIgA antibodies.
For patients with a deficiency of IgA without anti-IgA antibodies who receive frequent
transfusions.
Washed red cells can be used in patients who experience recurrent severe allergic-type
transfusion reactions (fever, generalised urticaria and/or dyspnoea) associated with red cell
transfusions
Washed red cells must be used within 24 hours after preparation.
Should washed red cells not be ready in time (washing takes 23 hours) due to the urgency of
the transfusion, standard products should be used whilst being ready to manage a possible
anaphylactic reaction.
Irradiated red cells
Used to prevent graft-versus-host reactions.
Immunocompromised patients
Stem cell transplant recipients, some patients with haematological diseases
Very low birth weight premature infants (see hospital-specific guidelines)
Irradiated red cells should be used soon after irradiation, within a week for adult patients.
Local and national guidelines apply.

Platelet transfusion
Indications
Indications for a platelet transfusion include
management of haemorrhage due to thrombocytopenia
replacement of platelets in a massive haemorrhage
supportive therapy to prevent bleeding in cancer or malignant haematological diseases if the
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patient has thrombocytopenia

prevention of bleeding during medical interventions in patients with thrombocytopenia or
platelet dysfunction.

Aims
The platelet transfusion threshold, target platelet count and the number of units needed is based
on the nature of the underlying disease, as well as the stage and goal of its treatment. The
transfusion threshold is also influenced by other factors that increase the risk of bleeding, such as
anticoagulant therapy or a planned surgical intervention.
After cytostatic chemotherapy, when the patients bone marrow fails to produce blood cells,
prophylactic platelet transfusions are indicated when the platelet count is < 10 109 /l.
Prophylactic platelet transfusions are indicated in severe infections and during anticoagulant
therapy when the platelet count is < 2030 109 /l.
Prophylactic transfusions comprise 12 units. The response to transfusion is estimated by
measuring the platelet count before the transfusion and about one hour after, or the next
morning. After one hour, the expected post-transfusion platelet count increment following a
transfusion of two units is 4050 109 /l of which about 60% should remain the following morning.
Reduced response to a transfusion may be due to various transient causes, such as fever,
sepsis, DIC, splenomegaly, certain medicines, vasculitis and graft-versus-host reaction.
Immune refractoriness due to, for example, the presence of anti-HLA (common) or HPA- (rare)
antibodies or platelet autoantibodies may result in long-lasting poor transfusion response.
Platelet transfusions are indicated for the management of clinically significant haemorrhage in a
thrombocytopenic patient when the platelet count falls below 50 109 /l. The management of
haemorrhage needs 24 units of platelets depending on the nature and site of the bleeding as well
as the pre-transfusion platelet count. During a surgical procedure a platelet count needs to be >
50 109 /l so as not to cause or maintain bleeding.

Selecting platelets for transfusion

The patients ABO and RhD groups must be determined before a platelet transfusion. Platelets to
be transfused are usually matched for ABO- and RhD type. No compatibility testing (cross
matching) is carried out for platelets.
It is also possible to transfuse ABO incompatible platelets to manage an acute bleed or other
acute situations. Platelet transfusion guidelines as regards the ABO groups differ from those given
for red cell transfusions. See local and national guidelines.
Modern platelet concentrates only contain a small amount of plasma and, therefore, the
isoagglutinins within the product do not cause significant harm to the recipient. However, a
transfusion that is incompatible with the recipients isoagglutinins (for example, group A platelets
to a group O recipient) may slightly reduce the transfusion response.
Since platelet concentrate will also contain some red cells, the RhD group must be considered
when transfusing platelets. An RhD positive patient should received RhD positive platelets and an
RhD negative patient RhD negative platelets.
An RhD negative patient may need to be transfused RhD positive platelets in exceptional
circumstances, when no RhD negative platelets are available. Transfusing RhD positive platelets
may trigger the production of anti-D antibodies, which is particularly harmful for females of
childbearing potential.
The immunising effect of RhD positive products may be prevented by administering human anti-D
immunoglobulin. See local guidelines.
The majority of patients can be administered standard platelet concentrate derived from whole
blood; the platelets for one pack are pooled from 4 donors. If platelets are transfused to severely
immunocompromised patients, irradiated products are used to prevent graft-versus-host
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reactions. See section Red cell transfusion.

Patients, in whom no transfusion response is achieved with standard platelets and who have antiHLA and/or anti-HPA antibodies, must be transfused HLA and/or HPA matched platelets. These
products are collected by automated apheresis from blood donors who have undergone HLA
and/or HPA typing.

Plasma transfusion
Fresh frozen plasma (FFP) is widely used. The frozen plasma product OctaplasLG is used in some
countries. It is a registered medicinal product; see the Summary of Product Characteristics more
detailed information.
OctaplasLG must be matched for the ABO group. No compatibility testing (cross matching) is
needed for OctaplasLG. Since all red cells have been removed from the product, the RhD blood
group does not need to be considered.
In emergency situations, OctaplasLG blood group AB can be administered to all patients since
it is devoid of anti-A and anti-B isoagglutinins.
Coagulation factor assays must be carried out before the product is administered.

Administration of a blood transfusion

Essentials
Verification that the correct blood product is transfused to the correct patient
Correct identification of the patient and the product
Observation of the statutory obligation to maintain the traceability of the patient and the
blood product.
A medical practitioner must prescribe a blood transfusion. The prescription must state
the type of the blood component (red cells, platelets, plasma) and the volume to be
transfused
any special requirements, such as irradiation, washing, blood group or tissue type requirements
instructions regarding the speed of transfusion, the possible need to warm the product or any
other factors to be considered, as necessary.
Before the transfusion, the nurse carrying out the transfusion must check
the prescription with its instructions
that the product is intended for the patient in question
The unit number on the product must match the number on the patients compatibility test
(cross match) form issued by the laboratory.
that the necessary compatibility tests have been carried out and the product has been found
to be suitable
Note: If the patient has red cell antibodies, the label on the red cell pack to be transfused
must be checked to ensure that the bag does not contain that particular blood group (for
example, if the patient has anti-E red cell antibodies, the label must state E).
the blood product visually for defects.
The integrity and cleanliness of the bag. The label must be well adhered to the bag.
No clots, aggregates, gas or abnormal colour, which could be suggestive of bacterial
contamination.
When inspecting platelet concentrates against light the presence of swirling should be
observed indicating their activity.
Verification of the patients identity
The identity can only be verified at the bedside not, for example, in the nurses office. The
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patient is asked to state his/her name and other identity data.

The identity data must be checked against the data on the compatibility test (cross match)
form.
If the patient is unable to reliably state his name and identity data, a person familiar with the
patient verifies the identity of the patient. For example, two members of the nursing staff can
verify the patients identity before the transfusion is started.
A code of practice for emergency transfusions should be available at hospitals.
The verification of identity and all checks must be recorded on the transfusion form or another
document as per hospital protocol.
Ensuring the traceability of a blood product
There is a statutory obligation to ensure the traceability of the blood product from the
recipient to the donor and vice versa.
The sticker on the blood product, indicating the unit number, must be attached to the
transfusion form, or the transfusion is entered in the electronic patient record system as per
hospital protocol.
Administration of a blood transfusion
A blood administration set with an integral 150200 m filter is used to transfuse all blood
products.
The patient's heart rate, blood pressure, temperature as well as the start and end times of the
transfusion are recorded.
If possible, a transfusion is started slowly with a biological pre-check.
Red cells are infused slowly (1015 drops/min) during 10 minutes whilst carefully observing
the patient.
The same administration set may be used to transfuse several packs of red cells without
interruption, but it is recommended that the administration set is changed after six hours in
order to reduce the risk of bacterial contamination.
It is recommended that platelets are administered via a separate administration set or they
may be transfused first, if the plan is to transfuse red cells and platelets in succession.
Due to the possibility of transfusion reactions, the patient must be monitored throughout the
entire transfusion.
In normovolaemic anaemia, a bag of red cells can be infused over 23 hours. Red cell transfusion
should be completed within six hours of removing the pack from the refrigerator to room air. When
red cells are transfused to manage haemorrhagic anaemia, the degree of anaemia and the extent
of bleeding determine the speed of transfusion.
The blood pack and the administration set are recommended to be stored after the transfusion for
24 hours in case of possible adverse reactions.

Blood transfusion reactions, near miss incidents and mistransfusion

Terminology
Serious transfusion reaction is an incident that
results in death or is life threatening
results in disability or incapacity
results in, or prolongs, hospitalisation
results in, or prolongs, morbidity
Serious near miss incident
An incident that might have resulted in a serious transfusion reaction
Mistransfusion
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Patient transfused with blood of the wrong blood group

Patient transfused with a wrong component or product
Patient transfused with blood intended for another patient even if the blood group and other
requirements were correct

Blood transfusion reactions

Each transfusion has the potential to cause a reaction.
National and local surveillance procedures apply as regards the reporting of serious transfusion
reactions, near miss incidents and mistransfusions.
The majority of transfusion reactions are mild and harmless to the patient, and it is not possible to
totally avoid them.
Mistransfusion is often due to an error in the transfusion process.
Most commonly the patient was misidentified or not identified at all.

Adverse reactions
Febrile reaction
The most common reaction associated with blood transfusions
The treatment of a mild febrile reaction, with or without rigors, is symptomatic and no followup investigations are required.
Fever is a feature of many other transfusion reactions, and the patient must be observed for
the emergence of any other symptoms.
Mild allergic reaction
A common transfusion reaction, the cause of which remains unknown. The patient is likely to
be allergic to a component of the blood product.
Symptoms consist of urticaria, other pruritic erythema, swelling of the lips, tongue or pharynx
and conjunctivitis
The reaction is usually caused by a single blood unit.
The reaction can be suspected to be caused by the transfusion if symptoms emerge during the
transfusion or within 4 hours after its completion and no other cause can be identified.
Antihistamines will relieve symptoms.
No follow-up investigations are required.
Severe allergic reaction or anaphylaxis
A rare transfusion reaction
Most likely caused by plasma proteins and soluble components. The reaction is usually caused
by a single blood unit.
The aetiology of an anaphylactic reaction may involve the formation of anti-IgA antibodies
against IgA in an IgA-deficient recipient. Typically develops at the start of, or during, the
transfusion but is also possible immediately after the transfusion has been completed.
Symptoms, including dyspnoea, generalised urticaria, hypotension, nausea and loss of
consciousness may quickly become life-threatening.
The treatment of the acute phase is symptomatic.
Careful planning is needed should the patient require transfusions in the future.
It may be possible to prevent reactions to subsequent transfusions by using washed blood
components (red cells and platelets), where the majority of the donor's plasma has been
removed.
Plasma products that contain IgA cannot be transfused to a recipient with anti-IgA
antibodies (contact local transfusion safety officials, if indicated).
Acute haemolysis
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A rare transfusion reaction, which may lead to serious complications

The transfused red cells are rapidly destroyed by the recipients red cell antibodies.
Usually caused by a transfusion error, resulting in ABO incompatibility, or other incorrectly
matched red cell transfusion.
Symptoms include fever, restlessness, chest and lower back pain, hypotension, respiratory
distress, oliguria or anuria as well as DIC-induced bleeding. The urine will become brownish-red
in colour.
The severity of symptoms is dependent on the number of red cells transfused and the antibody
levels.
Treatment concentrates on adequate hydration so as to prevent hypotension, hypovolaemia
and renal damage.
Delayed haemolysis
The symptoms are usually mild, and it is therefore likely that the condition is under-diagnosed.
The reaction is caused by red cell antibodies against other than the ABO blood group.
Usually due to existing red cell antibodies which have been boosted by a secondary immune
response.
Haemolysis develops about 14 weeks after a transfusion and the patient presents with
jaundice, anaemia or a darkening colour of the urine.
TRALI (transfusion associated acute lung injury)
Rare but serious transfusion reaction
Symptoms consist of acute respiratory insufficiency during or within 6 hours after the
completion of transfusion.
A chest x-ray will reveal bilateral pulmonary consolidation.
Without prompt management TRALI may prove to be fatal.
The pathogenetic mechanism of TRALI is not fully understood.
A possible aetiology could involve leucocyte antibodies in the donors plasma because the
more plasma transfused the higher the risk of TRALI.
TRALI must be differentiated from respiratory insufficiency due to, for example, volume
overload or left ventricular failure.
Infections and sepsis
Rare
Caused by a transfusion of contaminated blood.
The causative agent is usually bacteria that originate from the donors skin. Other infections,
such as blood-borne viral infections, are very rare.
Symptoms that emerge during the transfusion or immediately after its completion, including
high temperature, profound hypotension and nausea, are suggestive of bacterial contamination
of the blood product. Platelet products are more susceptible to bacterial contamination since
they are stored at room temperature.

Suspicion of a transfusion reaction and/or mistransfusion

Stop the transfusion immediately, but maintain vascular access.
An accidental transfusion of blood destined for another patient must be immediately reported
to the hospital blood bank.
This is done in order to prevent the possible transfusion of the switched blood to the other
patient and to ensure the traceability of the blood.
Treatment is symptomatic.
National guidelines apply as to the reporting procedure regarding a suspected severe transfusion
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reaction.
Country specific legislation will provide instructions regarding
the obligation of local health care units, blood banks etc. to keep records relating to
transfusion reactions and near miss incidents
the obligation to report serious transfusion reactions, and near miss incidents, associated with
blood quality and safety to appropriate bodies
recommendations to report other events, and near miss incidents, not associated with the
blood quality.

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