BLOOD TRANSFUSION

What is a blood transfusion? A blood transfusion is the transfer of blood or blood products from one person (donor) into another person's bloodstream (recipient). This is usually done as a life saving maneuver to replace blood cells or blood products lost through severe bleeding, during surgery when blood loss occurs or to increase the blood count in an anemic patient. The following material is provided to all patients and/or their family members regarding blood transfusions and the use of blood products. Although in most situations the likelihood of a blood transfusion associated with surgery is uncommon, at times patients may require blood products. You are encouraged to discuss your particular need for transfusion as well as the risks of transfusion with your doctor.

Blood Component ABO Compatibility Chart Red Blood Cells and Plasma
COMPATIBLE Patient's ABO Group Antigen on Red Cells Antibody in Serum Whole Blood Red Blood Cells

Plasma

No A or B

Anti-A Anti-B

O A B AB A AB B AB

Anti-B

A O B O AB A B O

Anti-A

AB

A and B

None

AB

AB

Platelet and Cryoprecipitate Compatiblity While the same ABO type as the patient is the first choice, any ABO and Rh type may be transfused.

Rh COMPATIBILITY
Rh Positive Patient Rh positive Rh negative Components or Rh Negative Patient Only Rh negative Components

 RH - a blood group antigen possessed by Rh-positive people; if an Rh-negative person receives a blood transfusion from an Rh-positive person it can result in hemolysis and anemia.  Rh factor, rhesus factor antigen - any substance (as a toxin or enzyme) that stimulates an immune response in the body (especially the production of antibodies)

As a clinician one will have to be aware of:

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Indications for blood transfusion. Alternatives to blood transfusion. Administration of blood. Transfusion reactions. Informed consent for blood transfusion. Component therapy. Do's & Don'ts of blood transfusion.

Ordering Blood : Safe transfusion practice begins with correct identification of the intended recipient. Blood samples of the recipient should be identified and labeled properly. Test recipient's blood for ABO Group, Rh type, Coomb's & crossmatch. STEPS AT THE TIME OF ISSUE OF BLOOD :

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Identify intended recipient. Compare ABO group and Rh type of the primary label and transfusion form. Inspect color & expiry date of blood bag. Blood bag with clots, pinkish discoloration of plasma, purple discoloration should not be issued. Record of issuing person, Date, Time and person to whom issued is to be maintained so that in case of an adverse reaction the person can be contacted to help identify the cause of transfusion reaction.

ISSUING OF BLOOD AND BLOOD COMPONENT :

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Administer blood within half an hour of issue from blood bank. Hour time limit is empirical and is the time taken for blood bag to reach 10 degree Celsius temp. N o blood bank will accept blood back if it has reached 10-degree temp and it has to be discarded. Non medical reasons for delay in starting blood transfusion can be avoided by properly educating transfusionist. Open system of blood e.g. saline washed RBC should be used within 24 hr. Blood components like cryoprecipitate & FFP should be used with in 6 hrs of issue. In case of delay in initiating blood transfusion return the blood bag to blood bank immediately. Don't store blood or blood component in unmonitored nursing station refrigerator as storage temp for blood of 0 to 4 degree Celsiuscannot be assured and gives a false sense of security.

This is a common practice in small nursing homes and ICCU and surgicaltheaters of most institutions. Platelet bags should not be stored in a refrigerator, it should be maintained at 22 to 24 degree Celsius on a constant agitator.

STEPS AT THE TIME OF INFUSION :

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Check all identifying information. Identity the recipient on transfusion form, compatibility label, ABO group, Rh type, Donor unit identification no. & Expiry date. Transfusionist must start transfusion only on physician's "written orders".

STARTING THE TRANSFUSION :

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Record Date and Time of beginning and termination of blood transfusion. Record amount of blood transfused. Patient's record should be checked once again to verify correct identification. Record patient's vital parameters prior to initiation of blood and then every 15 minutes, as changes in vital parameters are the first changeto occur in case of a transfusion reaction.

CARE DURING TRANSFUSION :

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First half an hour is crucial. Risk of catastrophic event like ABO hemolytic reaction and anaphylactic reaction is maximum in the first hr. Risk declines sharply after hr. Record vital signs every 15 minutes. Increase rate of infusion to required rate. Observe through out transfusion.

RATE OF INFUSION OF BLOOD :

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First hr is slow. If no reaction, increase the rate depending on recipient's hemodynamic status. o If haemodynamically stable, transfuse over 2 hours. o If haemodynamically unstable, transfuse over 4 hours. This time limit is empirical based on the time it takes the blood bag to reach room temperature. 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 transfusion over a longer period ask for split units of blood from blood bank and give each over 4 hours. Rapid infusion may be necessary in certain clinical setting, then use mechanical devices for rapid infusion of blood. Blood pressure cuff is unsuitable for providing external pressure.

DISCONTINUING BLOOD TRANSFUSION :

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Record time, Volume and type of component given. Check patient's condition and vital parameters. Return transfusion form to transfusion service i.e. blood bank. Observe patient for one hour. Do post transfusion monitoring: HCT, platelet counts, coagulation factors. (delayed transfusion reaction may be recognized if there is inappropriate rise in HCT.) Monitor for PTH ( post transfusion hepatitis )

NEEDLES : y 21 OR 20 NO. SCALP VEIN OR VENFLOW y For Pediatric transfusion, use 23 no scalp vein. If BLOOD FLOW RATE IS SLOW : y Elevate blood container. y Check patency of needle and size. y Examine filter for excess debris. y Examine blood bag for presence of clot. y Add normal saline 50 to 100 cc. DON'TS FOR BLOOD TRANSFUSION :

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Don't use blood from unlicensed blood bank. Don't delay initiation of blood transfusion. Don't warm blood. Don't use routine pretransfusion medication. Don't infuse over more than 4 hrs. Don't leave patients unmonitored. Don't add any medication to blood bag. Discard blood if not utilized. Don't ask for all the blood bags at one time. Don't use unmonitored refrigerator for storage. Don't use the same transfusion set for more than one blood bag. Do not wet outlet port of blood. Don't store platelet in refrigerator. Don't be complacent while checking identifying information. Don't insist for immediate relative's blood and directed donation.

ADVERSE REACTIONS TO BLOOD TRANSFUSION

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Any adverse reaction that occurs during the administration of blood and blood component must be considered as transfusion reaction unless proved otherwise. Transfusion reactions occur in 7% to 10% of all recipient of blood or blood components. Fortunately, majority of them are minor reactions. 10% of these reactions are hemolytic and 90% of these are nonhemolytic reactions. Incidence of ABO mismatch blood being infused is 1 : 30,000 blood bag. 1 out of 10 ABO mismatch transfusion is fatal .  Hemolytic: Referring to hemolysis, the destruction of red blood cells which leads to the release of hemoglobin from within the red blood cells into the blood plasma.

RECOGNITION OF ACUTE TRANSFUSION REACTION : Signs and symptoms of Acute hemolytic transfusion reaction:

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Fever with or without chills Rigors with or without fever Pain at infusion site or in chest, abdomen or flanks.

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Acute hypotension or hypertension. Tachypnea and hypoxemia. Nausea with or without vomiting. Hemoglobinuria. Urticaria , flushing , itching or edema

THE ROLE OF TRANSFUSIONIST IN CASE OF AN ACUTE TRANSFUSION REACTION: First is to suspect and then is to take action. STOP Transfusion immediately. NOTIFY responsible physician. MAINTAIN IV LINE with normal saline drip. CHECK for all identifying information for clerical error. Notify Blood bank personnel and patient's physician immediately.

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y Conditions requiring aggressive management need to be ruled out immediately. A physician must evaluate to rule outAcute hemolytic transfusion reaction , Anaphylaxis , TRALI , transfusion induced sepsis. y y
Initiate therapeutic actions.

Collect blood samples for the blood bank as directed by them usually 3-cc EDTA blood and 5 cc in plain tube.

y Blood for coagulation profile in a 10cc-citrate tube and plain tube for biochemistry , electrolytes and appropriate bloodcultures. y
Return discontinued blood bag along with IV administration set, attached IV solutions, all related forms and labels.

y In case the reaction is limited to urticaria or circulatory overload there is no need to evaluate post reaction blood or urine samples.
Monitor hemodynamic status , urine output , ECG.