Blood Transfusion services are a vital part of modern health care system without which efficient healthcare is impossible.

The aim of Blood transfusion services should be to provide effective blood & blood products, which are as safe as possible, & adequate to meet patients need. The Blood Transfusion services in our country are governed by the Drugs control Deptt. & we come under the Drugs & cosmetics act, 1940.

BLOOD DONATION
y Donor recruitment is critical to the success of supply

of safe & adequate blood & its products. y Donor recruitment strategies are: i. Pure voluntary & non remunerated based recruitments. ii. Replacement donors in case voluntary donors are not available. Hospital staff, specially clinicians can actively contribute in motivating the relatives & friends of patients, who had or will need blood transfusions.

The first & most important step in ensuring that Blood & its products for transfusion do not have any pathogenic virus & bacteria. All donors are there fore given educational material informing them of high risk activities for HIV, of the clinical signs & symptoms of HIV & AIDS & the importance of refraining from blood donation if they have been engaged in these activities. Age 18 60 yrs In good health Weight more than 45 kgs Hb > 12.5 g%

The ABO Rh system

yA yB yO y AB

Universal Donor Universal Recipient

Plasma ABO compatibility chart:

Recipient s Blood Group group yO yA yB y AB Plasma Donor s blood O, A, B, AB A, AB B, AB AB

Rh + plasma should not be given to Rh - women in reproductive age.

BLOOD COMPONENTS
y Blood collected in the blood center is WHOLE

y y y y y

BLOOD Whole blood is then separated into various components: PLASMA PLATELETS RED BLOOD CELLS CRYOPRECIPITATE Pediatric purposes- Smaller volumes Dividing a unit of whole blood in a closed system into satellite bags

Shelf Life of Blood Components:

y Whole Blood y y y y

: 21 to 35 days Red Cells : 42 days Platelets : 5 days FFP : 1 yr Cryoprecipitate : 1yr

TRANSFUSION MEDICINE PROCESS MAPPING

y

Blood Request Form (90)

FORM Blood/ Blood Component Requisition

y y y y

Blood Issue . (90 A) Blood Component Issue Blood Receipt Report from Ward to BB Consent for Blood Transfusion Blood Transfusion at Ward

..Blood Component Issue Note

Compatibility Report & Sticker (generated online by BB) . .Blood Received Register

..Consent Form for transfusion of blood/ blood components (25) .Blood Transfusion Note

Transfusion Reporting to BB from Ward Component Compatibility Report)

Post-transfusion Form (2nd part of Blood

Transfusion Reaction Investigation by BB

. Transfusion Reaction Investigation Form

Administration of blood products:

y A physician or a qualified nurse should administer

blood and blood products. y Before starting transfusion, patient identity check should be done at the patient s bedside & from the records of the patients. y Ask the patient himself/herself the name, if the patient is unconscious identify the patient with wristband.

y Check the following details on the compatibility

y y y y y

report, and the compatibility label attached to the blood product: Patient s name Reg. no. Blood group Bag no. Collection and expiry dates of Blood There should be no discrepancy.

Check the blood pack:

y Any sign of damage or leakage of the blood/its

product. y Collection and expiry date on blood pack. y Any clot y If the pack appears abnormal in any way, the unit must not be transfused and the blood bank must be informed immediately.

Time limits for infusion

Whole blood or Red cells y The administration of whole blood or red cells should be started within 30 minutes of issuing from the blood bank. If it is not required for transfusion it should be returned immediately to the blood bank with reasons. y Transfusion should be completed within 4 hours of starting the transfusion. These time limits have been determined for temperate climates where temperature in hospital building is between 22oC and 25oC. If the ambient (room) temperature is very high, shorter outof-refrigerator times should be used. y Change the blood administration set after 2 hours, if the patient requires ongoing transfusion support.

Platelet Concentrates
y Platelet concentrate should be administered as soon as y y y y

they have been received. Infusion should be completed within about 15-20 minutes. Should be kept at room temperature 22oC and 24oC. Do not put in refrigerator. Should be administered with transfusion set with filter. Platelets once issued are not taken back in the blood bank.

Fresh Frozen Plasma

y FFP should be infused as soon as possible after thawing

to avoid loss of labile clotting factors or thawed plasma stored at 2-4oC should be used within 12 hours. y In adult, 1 unit of plasma should generally be infused with in about 15-20 minutes. y Thawed or partially thawed plasma is not taken back in the blood bank

Disposable equipment for transfusion:

y Whole blood, red cells, platelet concentrate, plasma

and cryoprecipitate are infused though sterile blood administration set containing 170-200 micron filter.
y Leukocyte-depleting filters are expensive but they are

effective in reducing the febrile non-hemolytic transfusion reactions and the development of antileukocyte antibodies in multiple-transfused patients.

Monitoring the transfused patients:

For each unit of blood transfused, monitor the patient at the following stages: I. Before starting the transfusion II. As soon as the transfusion is started III. For 15 minutes after starting transfusion IV. At least every hour during transfusion V. On completion of the transfusion VI. 4 hours after completing the transfusion

At each of these stages, record the following information:

y Patient s general appearance y Temperature y Blood pressure y Respiratory rate y Sign of any adverse reaction

these signs are fever with back pain (acute hemolytic transfusion reaction), anaphylaxis, hives or pruritus (urticarial reaction). Congestive heart failure (volume over load) or fever alone (febrile non-hemolytic transfusion reaction).

y Monitor the patient carefully during the first 15

minutes of the transfusion to detect any early signs and symptoms of adverse effects. y The adverse effects of transfusion are usually doserelated, therefore, very slow transfusion rates are used at the start, 15 to 50 ml are given during the first 15 minutes. Once the transfusion is progressing satisfactorily, the infusion rate can be increased so that the product is transfused within a reasonable time depending on the clinical condition of the patient.

y Only isotonic (0.9 percent) saline or 5% albumin

should be used to dilute blood components or can be infused with the transfusion set, because other I.V. solutions like dextrose solutions such as 5% dextrose in distilled water may damage the red cells and cause hemolysis or calcium containing solutions such as lactated Ringer s solution initiate coagulation in the infusion set. In addition, many drugs will cause hemolysis if injected through the blood infusion set.

Blood Warming
Routine warming of blood is not needed; infusing 2-4 units of refrigerated blood over several hours causes no harm. Patients who may need benefit from warmed blood include: i. Adults receiving multiple transfusions at rates greater than 50 ml/kg/hr. ii. Children receiving transfusion at rates greater than 15 ml/kg/hr. iii. Infants receiving exchange transfusion iv. Patients receiving rapid transfusion through central venous catheter. v. Patients with cold agglutinins. The rapid and massive transfusion of cold blood (2-6oC) is associated with an increased risk of ventricular fibrillation and cardiac arrest.

Blood warming procedure:

y It is carried our using approved blood warmer devices. y Blood is never warmed above 37oC. Excessive warming

can cause hemolysis and endanger the patient. If blood warmers are being used they should be tested before use to ensure that the temperature regulators are operating properly. y Do not immerse whole unit of blood or red cells in a water bath.

Transfusion reactions:
y Any adverse effect caused by transfusion may be

considered a transfusion reaction. Some are mild, others are life-threatening. y All reactions should be documented and reported.

Category 1 Mild reaction:

Signs Localized: Urticaria Rashes Symptoms Itching Possible cause Hypersensitivity (mild)

Moderately Severe:
signs -Flushing -Urticaria -Rigor -Fever -Restlessness -Tachycardia symptoms -Anxiety -Pruritus (itching) -Palpitations -Mild dyspnoea -Headache Possible cause -Hypersensitivity (moderately severe) -Febrile non-hemolytic transfusion reactions -Antibodies to while blood cells, platelets. -Antibodies to proteins, including IgA. -Possible contamination with pyrogens and/or bacteria.

Life-Threatening
signs Rigors Fever Restlessness Hypotension (fall of > 20% in systolic BP) Tachycardia (rise of > 20% in heart rate) Haemoglobinuria (red urine) Unexplained bleeding (DIC) symptoms Anxiety Chest pain Pain near infusion site Respiratory distress/shortness of breath Loin/back pain Headache Dyspnoea Possible cause -Acute intravascular haemolysis -Bacterial contamination and septic shock. -Fluid overload -Anaphylaxis, -Transfusion associated lung injury.

Causes:
Clerical errors y Inadequate or incorrect labeling of Blood Bag, recipient s blood sample. y Confusion in the identity of patients at the time of collection of sample or at the time of transfusion y Improper identification of patient s blood sample by blood bank technician y Wrong blood issued Technical errors y Error in blood grouping & cross matching. y Incompatibility not detected in cross matching due to improper method. y Weak antibodies not detected by routine tests. y Destruction of recipient red cells by donor ab - may not be serious as donor antibodies are diluted in patient s blood. It mostly occurs in transfusion of group O to other groups. y Incorrect interpretation of test results.

Management in Adverse Transfusion Reactions

Category I: Mild y Stop transfusion. y Replace the given set and keep I.V. line open with normal saline. y Notify the doctor responsible for the patient. y Administer antihistamine IM and oral antipyretic (eg. Paracetamol). y Send blood unit with giving set, fresh blood samples (1 clotted and 1 in EDTA) from vein opposite to infusion site with appropriate reaction form to blood bank of investigations. y Collect urine for next 24 hrs. for evidence of haemolysis and sent to laboratory. y In clinical improvement, restart transfusion slowly with new blood unit if required and observe carefully. y If no clinical improvement with in 15 minutes or if signs and symptoms worsen, treat as Category 2.

Category 2 : Moderately Severe/Life-threatening

y Stop the transfusion, replace the giving set and keep I.V. line open with normal saline. y Infuse normal saline (initially 20-30 ml/kg) to maintain systolic BP. y Notify the doctor responsible for the patient. y Maintain airway and given high flow oxygen by mask. y Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by intramuscular injection in severe allergic reaction. y Give I.V. corticosteroids and bronchodilators if there are anaphylactoid features (e.g. bronchospasm, stridor). y Give diuretic: e.g. frusemide . y Send blood unit with BT 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. y Check a fresh urine specimen visually for signs of hemoglobinuria (red to pink urine).

y Start at 24 hour urine collection and fluid balance chart and y

y y y y y y y y y

record all intake and output. Maintain fluid balance Assess for bleeding from 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). Reassess. If hypotension persists: Give further saline 20 30 ml/kg. Give Ionotrope (Dopamine, IV infusion) 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. 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.

Prevention:
y There should be a written procedure for all aspects of

procuring, issuing & administering transfusion. y All staff should be trained in proper use of equipment, IV solutions & drugs. y Medications should never be injected into Blood bags. y Care must be exercised in selection & use of IV devices.

SAFE TRANSFUSION

Safe Transfusion

BLOOD DONORS