NCM 106 (CMO # 14 S. 2009) and NCM 112 (CMO # 15 S.

of 2017)
Skills Laboratory
BLOOD TRANSFUSION
BLOOD TRANSFUSION

IS DEFINED AS THE PROCESS OF RECEIVING BLOOD PRODUCTS INTO ONE’S CIRCULATION INTRAVENOUSLY. THIS IS
USUALLY DONE AS A LIFE SAVING MANEUVER TO REPLACE BLOOD CELLS OR BLOOD PRODUCTSLOST THROUGH
SEVERE BLEEDING, DURING SURGERY WHEN SEVERE BLOOD LOSS OCCURS OR TO INCREASE THE BLOOD COUNT IN AN
ANAEMIC PATIENT
.•TRANSFUSIONS USUALLY INVOLVE THE USE OF TWO SOURCES OFBLOOD – ONE’S OWN (AUTOLOGOUS TRANSFUSION)
OR SOMEONE ELSE’S (ALLOGENIC TRANSFUSION).
•BLOOD TRANSFUSIONS INVOLVES THE USE OF WHOLE BLOOD ,RED BLOOD CELLS, WHITE BLOOD CELLS, PLASMA,
CLOTTING FACTORS AND PLATELETS.

BLOOD & BLOOD PRODUCTS

•BLOOD IS COLLECTED FROM DONORS WHO HAVE BEEN PREVIOUSLY SCREENED TO EXCLUDE ANY BLOOD OR BLOOD
PRODUCTS THAT MAY HAVE THE POTENTIAL TO HARM THE PATIENT
.•EACH UNIT OF BLOOD IS TESTED FOR EVIDENCE OF HEPATITIS-B,HEPATITIS-C , HUMAN IMMUNODEFICIENCY VIRUS I &
II ANDSYPHILIS
.•THE ABO AND RHESUS D BLOOD GROUP IS DETERMINED AS WELL ASTHE PRESENCE OF IRREGULAR RED CELL
ANTIBODIES.
•THE BLOOD IS THEN PROCESSED INTO SUB-COMPONENTS.

WHOLE BLOOD

•WHOLE BLOOD IS UNSEPARATED BLOOD CONTAINING AN ANTICOAGULANT –PRESERVATIVE SOLUTION. ONE UNIT OF
WHOLE BLOOD CONTAINS
-• 450 ml OF DONOR BLOOD
.• 50 ml OF ANTICOAGULANT-PRESERVATIVE SOLUTION.
• HAEMOGLOBIN approx. 12g/ml & HAEMATOCRIT 35% - 45%.
• NO FUNCTIONAL PLATELETS.
•SINCE IT IS NOT STERILIZED, CAPABLE OF TRANSMITTING ANY AGENT PRESENT IN CELLS OR PLASMA WHICH HAS NOT
BEEN DETECTED BY ROUTINE SCREENING.
•HOWEVER WHOLE BLOOD TRANSFUSION HAS SIGNIFICANTADVANTAGES OVER PACKED CELLS AS IT IS COAGULATION
FACTOR RICHAND IF FRESH, MORE METABOLICALLY ACTIVE THAN STORED BLOOD.
• STORED BETWEEN +2 AND +6 DEGREES CENTIGRATE IN A BLOODBANK REFRIGERATOR
.•TRANSFUSION SHOULD BE STARTED WITHIN 30 MINUTES OFREMOVAL FROM THE REFRIGERATOR AND COMPLETED
WITHIN 4HOURS OF COMMENCEMENT BECAUSE CHANGES IN THECOMPOSITION MAY OCCUR DUE TO RED CELL
METABOLISM.
INDICATIONS –
•RED CELL REPLACEMENT IN ACUTE BLOOD LOSS WITHHYPOVOLAEMIA
•EXCHANGE TRANSFUSIONCONTRAINDICATIONS –•CHRONIC ANAEMIA
•INCIPIENT CARDIAC FAILURE

PACKED RED CELLS

•PACKED RED CELLS ARE CELLS THAT ARE SPUN DOWN AND CONCENTRATED.
•ONE UNIT OF PACKED RED CELLS IS APPROX. 330 ml AND HAS A HAEMATOCRIT OF 50-70%.
•THEY ARE STORED IN A SAG-M (SALINE-ADENINE-GLUCOSE-MANNITOL) SOLUTION TO INCREASE THEIR SHELF LIFE TO 5
WEEKS AT 2-6 DEGREES CENTIGRATE.
•IT CARRIES THE SAME INFECTION RISK AS IN WHOLE BLOOD.
•INDICATED IN REPLACEMENT OF RED CELLS IN ANAEMIC PATIENTSAND ALSO USED WITH CRYSTALLOID AND COLLOID
SOLUTIONS IN ACUTE BLOOD LOSS CONDITIONS.
FRESH FROZEN PLASMA

•FRESH FROZEN PLASMA IS RICH IN COAGULATION FACTORS

.•IT IS SEPARATED FROM WHOLE BLOOD AND STORED AT -40 TO -50DEGREES CENTIGRATE WITH A 2 YEAR SHELF-LIFE.
•IT IS THE FIRST LINE THERAPY IN THE TREATMENT OFCOAGULOPATHIC HAEMORRHAGE
.•ALSO USED IN THE REPLACEMENT OF MULTIPLE COAGULATIONFACTOR DEFICIENCIES LIKE LIVER DISEASE, WARFARIN
OVERDOSE,DEPLETION OF COAGULATION FACTORS IN PATIENTS RECEIVING LARGE VOLUME TRANSFUSIONS,
DISSEMINATED INTRAVASULAR COAGULATION AND THROMBOTIC THROMBOCYTOPENIC PURPURA.

PLATELETS

•PLATELETS ARE SUPPLIED AS A POOLED PLATELET CONCENTRATE CONTAINING ABOUT 250 X 10 9 CELLS PER LITRE.
•PLATELETS ARE STORED ON A SPECIAL AGITATOR AND HAVE A SHELFLIFE OF ONLY 5 DAYS
.•ARE USUALLY GIVEN TO PATIENTS WITH THROMBOCYTOPENIA OR THOSE WITH PLATELET DYSFUNCTION WHO ARE
BLEEDING OR UNDERGOING SURGERY AND IN PATIENTS WITH BONE MARROW FAILURE
.•NOT INDICATED IN –• PATIENTS WITH ITP, TTP, UNTREATED DIC AND IN CASES OFHYPERSPLENISM.
•DOSAGE – 1 UNIT OF PLATELET CONCENTRATE /10 kg BODY WEIGHT.
•4-6 DONOR UNITS OF PLATELET CONCENTRATES WILL RAISE THE PLATELET COUNT BY 20-40 X 109/L. INCREMENT WILL
BE LESS IF THEREIS ASSOCIATED SEPTICEMIA, DIC, SPLENOMEGALY.
•COMPLICATION S– FEBRILE AND ALLERGIC URTICARIAL REACTIONS ARE COMMONESPECIALLY IN PATIENTS RECEIVING
MULTIPLE TRANSFUSIONS
.• PATIENTS ON ASPIRIN THERAPY RARLELY POSE A PROBLEM BUT THOSE PATIENTS ON CLOPIDOGREL WHO ARE
ACTIVELY BLEEDING ANDUNDERGOING MAJOR SURGERY MUST BE GIVEN A CONTINUOUS INFUSION DURING THE
COURSE OF THE PROCEDURE.
CRYOPRECIPITATE

•CRYOPRECIPITATE IS A SUPERNATANT PRECIPITATE OF FRESHFROZEN PLASMA AND IS RICH IN FACTOR VIII AND
FIBRINOGEN.
•IT IS STORED AT -30 DEGREES CENTIGRATE WITH A 2 YEARS SHELFLIFE.
•INDICATED IN LOW FIBRINOGEN STATES (<1g/L) OR IN CASES OFFACTOR VIII DEFICIENCY (HAEMOPHILIA-A), VON
WILLEBRAND’SDISEASE AND AS A SOURCE OF FIBRINOGEN IN DISSEMINATEDINTRAVASCULAR COAGULATION.
•POOLED UNITS CONTAINING 3-6 gms FIBRINOGEN IN 200-500 ml RAISES THE FIBRINOGEN LEVEL BY APPROX. 1g/L
.•MUST BE INFUSED WITHIN 6 HOURS.

BLOOD GROUPS AND CROSS-MATCHING

•HUMAN RED BLOOD CELLS HAVE MANY DIFFERENT ANTIGENS ONTHEIR CELL SURFACE.
•TWO GROUPS OF ANTIGENS ARE OF MAJOR IMPORTANCE INMEDICAL PRACTICE – THE ABO AND THE RHESUS
SYSTEMS.
•ABO SYSTEM-THESE ARE STRONGLY ANTIGENIC AND AREASSOCIATED WITH NATURALLY OCCURING ANTIBODIES IN
THESERUM.THIS SYSTEM CONSISTS OF 3 ALLELIC GENES A, B & O.
•GROUP A & B CONTAIN SPECIFIC ANTIGENS AND PROVOKE AREACTION IF THESE ANTIGENS ARE NOT PRESENT IN THE
RECIPIENT.
•GROUP ‘O’ CONTAINS NO ANTIGENS TO PROVOKE A REACTION INTHE RECIPIENT AND HENCE CALLED ‘AMORPHS’.
•THEREFORE, BLOOD GROUP ‘O’ IS CONSIDERED AS THE UNIVERSALDONOR AS IT HAS NO ANTIGENS TO PROVOKE A
REACTION AND ‘AB’BLOOD TYPE IS CONSIDERED AS THE UNIVERSAL RECIPIENTS ASTHEY HAVE NO CIRCULATING
ANTIBODIES TO THEM.
•RHESUS SYSTEM- THE RHESUS D ANTIGEN IS STRONGLY ANTIGENICAND IS PRESENT IN APPROXIMATELY 85% OF THE
POPULATION.ANTIBODIES TO THE ‘D’ ANTIGEN ARE NATURALLY NOT PRESENT INTHE REMAINING 15% OF THE
INDIVIDUALS BUT THEIR FORMATIONMAY BE STIMULATED BY THE TRANSFUSION OF RH’+’ RED CELLS ORTHEY MAY BE
ACQUIRED DURING DELIVERY OF A RH-D-POSITIVEBABY LEADING TO HAEMOLYTIC DISEASE OF THE NEWBORN IN
ASUBSEQUENT PREGNANCY.
MAKING THEDECISION FORBLOODTRANSFUSION
•IF USED CORRECTLY, BLOOD TRANSFUSION CAN BE LIFE-SAVING, IN APPROPRIATE USE CAN ENDANGER LIFE.
•THE DECISION TO TRANSFUSE BLOOD OR BLOOD PRODUCTSSHOULD ALWAYS BE BASED ON A CAREFUL ASSESSMENT
OF CLINICALAND LABORATORY INDICATIONS THAT TRANFUSION IS NECESSARYTO SAVE LIFE OR PREVENT SIGNIFICANT
MORBIDITY.
MINIMIZING THE NEED FOR BLOOD TRANSFUSION

•Preoperative planning-
•History and examination including surgical or bleeding history
•Full blood count, blood chemistry, coagulation,
•Consider autologous blood deposit
•Consider erythropoietin to boost hemoglobin concentration
•Treat iron or folate deficiency
•Stop aspirin prophylaxis if possible
•Day of admission
•Check if taking aspirin, non-steroidal anti-inflammatory drugs, anticoagulants
•Repeat full blood count
•Consider drugs to reduce bleeding (such as aprotinin)

During surgery

•Be prepared for longer duration to secure homeostasis

•Consider hypotensive surgery if appropriate
•Avoid hypothermia—give all fluids through a warmer
•Consider fibrin glues and sealants Postoperative care
•Accept lower postoperative hemoglobin concentration
•Accept transfusions of just one unit of blood, to exceed transfusion trigger
•Use continuous face mask oxygen if patient has low hemoglobin concentration
•Prescribe iron and folic acid routinely
•Consider Tranexamic acid

FACTORS DETERMNING THE NEED FOR THE GLOOD TRANSFUSION

•EXTERNAL BLEEDING & MEDICAL CONDITIONS LIKE THALASSEMIA.

•INTERNAL BLEEDING –Eg. VARICEAL BLEEDING, ECTOPIC PREGNANCY,ANTEPARTUM HAEMORRHAGE , RUPTURED
UTERUS,TRAUMATIC INJURIES TO THE CHEST, SPLEEN, PELVIS, LUNGS, RED CELLDESTRUCTION AS IN MALARIA,
SEPSIS, DISSEMINATED INTRAVASCULARCOAGULATION.
•CARDIORESPIRATORY STATE AND TISSUE OXYGENATION – BP, PULSE, RESPIRATORY RATE, CAPILLARY REFILL TIME,
PERIPHERAL PULSES, TEMPERATURE, URINE OUTPUT, CARDIAC FAILURE
.•ASSESSMENT OF ANAEMIA – CLINICALLY FROM THE TONGUE, PALMS,EYES, NAILS AND FROM LABORATORY
ASSESSMENT OF THE HAEMOGLOBINLEVEL OR HAEMATOCRIT.
•ANTICIPATED SURGERY WHERE POST-OPERATIVE BLOOD LOSS IS HIGHLY PROBABLE, CONTINUOUS BLEEDING OR
LIKELIHOOD OF RECURRENCE OFBLEEDING, CONTINUING HAEMOLYSIS.
.
SAFE BLOOD TRANSFUSION PROCEDURES

1. EVERY HOSPITAL SHOULD HAVE WRITTEN STANDARD OPERATING PROCEDURES FOR THE ADMINISTRATION OF
BLOOD PRODUCTS LIKETHE ONE WE HAVE IN OUR HOSPITAL , PARTICULARLY FOR THE FINALIDENTITY CHECK
OF THE PATIENT, THE COMPATIBILITY LABELDETERMINING THE PATIENT’S ABO AND RH-D GROUP, UNIQUE
DONATION NUMBER OF THE BLOOD PACK, BLOOD GROUP OF THEBLOOD PACK, THE DATE OF COLLECTION AND
THE EXPIRY DATE, THEINDICATION FOR TRANSFUSION, SIGNATURE OF THE CLINICIANPERFORMING THE PRE-
TRANSFUSION IDENTITY CHECK AND THETRANSDUSION PROCEDURE
2. THE BLOOD PACK SHOULD ALWAYS BE INSPECTED FOR SIGNS OFDETERIORATION ON ARRIVAL AND BEFORE
TRANSFUSION IF NOT USEDIMMEDIATELY.
3. DISCOLOURATION OF THE BLOOD PACK AND ANY SIGNS OF LEAKAGEINDICATE CONTAMINATION AND COULD
CAUSE A SEVERE FATALREACTION IF TRANSFUSED.
DISPOSABLE EQUIPMENT FOR BLOOD ADMINISTRATION

• CANNULAS MUST BE STERILE AND MUST NEVER BE REUSED.

• FLEXIBLE PLASTIC CANNULAS SHOULD BE USED AS THEY ARE SAFERAND PRESERVE THE VEINS. FOR WHOLE BLOOD,
RED CELLS, PLASMA & CRYOPRECIPITATE
•USE A NEW STERILE BLOOD ADMINISTRATION SET CONTAINING ANINTEGRAL 170-200 micron FILTER
• CHANGE THE SET AT LEAST 12 HOURLY DURING BLOOD COMPONENTINFUSION
.• IN A WARM CLIMATE, CHANGE THE SET MORE FREQUENTLY ANDUSUALLY AFTER EVERY 4 UNITS OF BLOOD IF GIVEN
WITHIN A 12HOUR PERIOD.
• THERE IS NO EVIDENCE THAT WARMING BLOOD IS BENEFICIAL TOTHE PATIENT WHEN INFUSION IS SLOW. AT INFUSION
RATES>100ml/minute, COLD BLOOD MAY BE A CONTRIBUTING FACTORIN CARDIAC ARREST. HOWEVER, KEEPING THE
PATIENT WARM ISPROBABLY MORE IMPORTANT THAN WARMING THE INFUSED BLOOD !
• WARMED BLOOD IS MOST COMMONLY REQUIRED IN LARGEVOLUME RAPID TRANSFUSIONS & EXCHANGE
TRANSFUSION ININFANTS.
•BLOOD SHOULD ONLY BE WARMED IN A BLOOD WARMER THATHAVE A VISIBLE THERMOMETER AND AN AUDIBLE
WARNINGALARM AND SHOULD BE PROPERLY MAINTAINED.

INTRAVENOUS CANNULATIONS FOR BLOOD TRANSFUSION CAN BE DONE FROM –

• CEPHALIC VEIN
• BASILIC VEIN
• FOREARM VEINS
• GREAT SAPHENOUS VEINS

MONITORING THE TRANSFUSED PATIENT

1. FOR EACH UNIT OF BLOOD TRANSFUSED, MONITOR THE PATIENT

:• BEFORE STARTING THE TRANSFUSION
• 15 MINUTES AFTER STARTING THE TRANSFUSION
• AT LEAST EVERY HOUR DURING TRANSFUSION
• ON COMPLETION OF THE TRANSFUSION
• 4 HOURS AFTER COMPLETING THE TRANSFUSION

2. AT EACH OF THESE STAGES, RECORD

:• PATIENT’S GENERAL APPEARANCE
• BLOOD PRESSURE, PULSE, RESPIRATORY RATE
• FLUID BALANCE – ORAL AND IV FLUID INTAKE & URINARY OUTPUT.

3. RECORD:
• TIME WHEN THE TRANSFUSION IS STARTED
.• TIME WHEN THE TRANSFUSION IN COMPLETED
.• VOLUME AND TYPE OF ALL PRODUCTS TRANSFUSED.
• BLOOD PACK NUMBERS.
• ANY ADVERSE EFFECTS.SEVERE REACTIONS MOST COMMONLY PRESENT IN THE FIRST 15-30MINUTES OF A
TRANSFUSION THEREFORE THEY SHOULD BECLOSELY MONITORED DURING THIS TIME.IF THE PATIENT
APPEARS TO BE EXPERIENCING AN ADVERSEREACTION THE TRANSFUSION MUST BE IMMEDIATELY
STOPPEDAND URGENT MEDICAL ASSISTANCE SHOULD BE SEEKED FOR.

REFERENCES:
• the who handbook on the clinical use of blood – who blood transfusion safety , geneva , 2007.
• bailey & love’s short practice of surgery – 25th edition –2008.
• davidson’s principle & practice of medicine – 21st edition –2010.
• essential paediatrics – o.p. ghai – 6th edition.
• online text from the british medical journal –www.bmj.co.uk/bloodtransfusionsafety31781/o3.