BLOOD TRANSFUSION

PRESENTED BY: CAPT SEETHA P V

INTRODUCTION
• Transfusion of blood and its
components is of vital
importance in patient care.
• Human blood is covered in the
definition of ‘Drug’ under
Sec. 3(b)(i) of Drugs &
Cosmetics Act.
• Life saving but associated with
risks.
INCIDENCE
 India:

AHTR TRALI
20% 23%

Sepsi
TACO
s
34%
13%

TA-
Others
GvHD
1% 9%
HISTORY
• 1628: English physician
William Harvey discovers the
circulation of blood. Shortly
afterward, the earliest known
blood transfusion is
attempted.
• 1818: James Blundell
performs the first successful
transfusion of human blood to
a patient for the treatment of
postpartum hemorrhage.
 CONTD….
• 1900: Karl Landsteiner, an
Austrian physician, discovers the
first three human blood groups, A,
B, and C. Blood type C was later
changed to O.
Nobel Prize for Medicine for
this discovery in 1930.
• 1916: Francis Rous and JR
Turner introduced a citrate-
glucose solution that permitted
storage of blood for several days
after collection.
 CONTD…..
 1939- 40: The Rh blood group system is discovered by
Karl Landsteiner, Alex Wiener, Philip Levine, and
R.E.Stetson.
 1943: Loutit and Mollison of England introduced the
formula for preservative Acid-citrate-dextrose (ACD).
 1979 : A new anticoagulant preservative, CPDA-1,
extends the shelf life of whole blood and red blood cells
to 35 days.
 1983 : Additive solutions (Saline, Adenine, Glucose,
Mannitol) extend the shelf life of red blood cells to
42 days.
COMPOSITION OF BLOOD
• Blood is a circulating tissue consisting of three
types of cells.
1. Red Blood Cells  Erythrocytes (45%)
2. White Blood Cells  Leukocytes
3. Platelets  Thrombocytes
• The cells listed above are
suspended in a liquid known
as plasma (55%)
Blood Component vs Blood
Product
 Blood Component: Drug prepared, obtained, derived or
separated from a unit of blood drawn from a donor.
Components are prepared from the processing of a
whole blood donation or via automated apheresis
collection methods. It can further be modified through
Leukoreduction, Irradiation & washing
 Blood Product: means a drug manufactured or
obtained from pooled plasma or blood by fractionation,
drawn from donors.
 Blood products Blood components
(Plasma derivatives)

Albumin PRBC

Immunoglobulins Fresh Frozen Plasma

Clotting factors Platelets

concentrates

Cryoprecipitate

Granulocytes
PACKED RED BLOOD CELLS
 Preparation : Whole blood by
Apheresis collection
 Hematocrit : 70 – 80 %
 Volume : 350 ml
 Anticoagulant: Citrate phosphate
Dextrose Adenine (CPDA)
 Stored at 1-6 degree Celsius
 Life span – 120 days
 The increase of Hb from 1 unit of
RBC will be 1 gm/dl and hematocrit
will be 3%
PLATELETS

 Preparation: Apheresis
 Stored at 20-24oC

 Volume RDP: 50-70ml

SDP: 200-300ml
 Under continuous agitation

(60-70 strokes/min)
 Shelf life of 5 days

 Quality check : Swirling effect

FRESH FROZEN PLASMA
 Preparation :whole-blood or
apheresis collections and
stored & frozen within 8 hours
of its collection.
 Contains factor VIII, fibrinogen

& 200 units of each stable

factor.
 Volume : 200 – 220 ml
 Storage : -18oC or below.
 Shelf life: 1 year
CRYOPRECIPITATE
 Cold-insoluble plasma proteins
that precipitate in fresh frozen
plasma (FFP) when thawed to
between 1°C and 6°C.
 Contains fibrinogen, factor VIII,
von Willebrand factor (vWF),
factor XIII and fibronectin.
 Volume : 10-20ml
 Storage temperature: -18oC or
below.
 Shelf life of 1 year
BLOOD PRODUCTS
(Plasma derivatives)
o Orders for fractioned products must be made daily,
we are not able to do standing orders for products
o Available products include:
o Immune globulins – IVIG, RhIG, HepB IG
o Albumin- 5% and 25%
o Factor concentrates – F8, F9, vWB factor
o C-1-esterase
o Fibrinogen concentrates
o Prothrombin Complex concentrates
Blood Component Modification
Leuko depleted Blood Irradiated Blood
 To reduce the WBC in Irradiated by gamma
blood products by leuco radiation from cobalt- 60 and
reduction filters and cesium-137 by Irradiator
apheresis machine Machine
 To decrease febrile Destroys the donor’s
reaction T Lymphocytes
 To prevent allo To prevent TA-GvHD
immunisation
 To reduce CMV
transmission
Transfusion of Blood Components
Transfusion of ‘Blood Components’ is –
When, specific portion or fraction of blood that is lacking in
a patient is transfused.

Advantages of blood component therapy

 Avoids the risk of sensitizing the patients to other blood
components.
 Provides optimal therapeutic benefit while reducing risk
of volume overload.
 Increases availability of needed blood products to larger
population.
 Thus it is a safe and risk procedure
Nursing Responsibilities
 Generate Demand
 Informed consent

 Pre-transfusion

considerations:
 Patient identification

 Premedication

 Vitals signs

 Inspection of unit

 Venous access

 Infusion sets

 Infusion rate

 Compatible fluids
How to generate a demand
 Should contain patient HID no,
A&D no., Patient name, ward
details, diagnosis, sample
collected by, date and time of
collection of sample.

 Mention whether most urgent,

urgent or routine.

 Mention requirement - PRBC,

Platelets, Cryoprecipitate and FFP
 Demand separately for each
component

 Sign and seal of doctor

Informed Consent
 Informed consent should be obtained from the intended
recipient before all non-emergency administration of
blood components.
 Elements of consent:

 Description of the risks.

 Benefits of transfusion.

 Treatment alternatives.

 Opportunity for the patient to ask questions.

 Right of the patient to accept or refuse transfusion.

Inspection of the Blood
Unit
 At least 02 Nursing Officer check the blood for the
following :
 Serial Number
 Blood Component
 Blood type & RH factor
 Date of Expiry
 Screening test
 Storage bag
 Warm blood at room temperature before transfusion.
Venous access
 Intravenous catheter for use
in transfusing cellular blood
components:
 - 20 to 18 gauge IV catheter is
suitable for the general adult
population.
 - 24 to 22 gauge intravenous
catheter for an infant or a
toddler.

 There is an increased
possibility of hemolysis when red
cells are transfused rapidly using
handheld syringes through 23-
gauge or smaller needles
INFUSION SETS
 Special IV tubing with a filter
designed to remove blood clots and
particles
 170-260 micron (macroaggregate)
filter.
 Primed with either 0.9% sodium
chloride or the component itself.
 A possible option is to have a three-
way stopcock close to the infusion
site that allows for the administration
of 0.9% sodium chloride.
 Suggested Adult Flow
Compone Rate Special ABO
nt Considerations Compatibility
First 15 After 15
Minutes Minutes

Red Blood 1-2 As rapidly as Infusion should Whole blood: ABO

Cells mL/min tolerated; complete within identical.
(RBCs – (60-120 Approxi- 4 hours of issue. RBCs: ABO
350ml) mL/hour) mately For patients at risk of compatible with
4mL/minute fluid overload, may recipient’s plasma.
or 240 adjust flow rate to as Crossmatch
mL/hour low as 1 mL/kg/hour required.

Platelets 2-5 300 mL/hour Usually given over Crossmatch not

mL/min or as 1-2 hours. required.
(120-300 tolerated For patients at risk of ABO/Rh
mL/hour) fluid overload, use compatibility
slower flow rate (as preferable, but not
in RBCs) required.
 Suggested Adult
Component Flow Rate Special ABO
Considerations Compatibility
First 15 After 15
Minutes Minutes

Plasma (FFP 2-5 As rapidly Thawing needed Crossmatch not

200-300ml) mL/min as before issue. required.
(120-300 tolerated; For patients at risk ABO compatibility
mL/hour) approx 300 of fluid overload, with recipient red
mL/hour use slower flow cells to be
rate. ensured.

Cryo As rapidly As rapidly Infuse as soon as Crossmatch and

precipitate as as tolerated possible after ABO compatibility
tolerated thawing. not required.
DOCUMENTATION
1. Transfusion order.
2. Recipient consent.
3. Component name.
4. Donation identification number.
5. Date and time of transfusion.
6. Pre and post-transfusion vital signs.
7. Volume transfused.
8. Identification of the transfusionist.
9. Transfusion-related adverse events.
POTENTIAL ADVERSE
EFFECTS OF
TRANSFUSION
Transfusion reaction
 Any transfusion - related adverse event that occurs
during or after the transfusion of whole blood, blood
components, or human-derived plasma products.

 May be difficult to diagnose as they can present with

non-specific, often overlapping symptoms.

 Some reactions can be prevented, whereas others

cannot.
PRECAUTIONS
 Avoidance of clerical errors
 Proper identification of the patient.
 Correctly labeled samples
 Proper identification of the recipient and the blood
pack
 Careful & close observation of the patient during
transfusion.
 Avoid unnecessary blood transfusion
 Transfusion Reaction
Potentially Life threatening:
 Acute Hemolytic transfusion reactions (AHTR – 20%)
 Transfusion-related acute lung injury (TRALI – 23%)
 Transfusion-associated circulatory overload

(TACO-34%)
 Transfusion-associated graft-versus-host disease

(TA-GvHD)
 Transfusion – associated sepsis (13%)

 Non Life Threatening:

 Allergic transfusion reaction (ATR)
 Febrile nonhemolytic reactions (FNHTR)
 Hypotensive transfusion reaction (1%)
Clinical features
SYMPTOMS SIGNS
Chills Fever
Chest / back pain Rigors
Headache Flushing
Itching Restlessness
Palpitation Hypotension
Dyspnoea Tachycardia
Nausea Urticaria
Vomiting Haemoglobinurea
Immediate Actions
 Stop the transfusion
 Patent intravenous line

 Confirm the correct product

 Assess the patient.

 Contact the transfusion service

 Can the transfusion be restarted ??

A decision regarding administration of further

transfusions must be reached with input from both the
treating physician and transfusion service.
Acute Hemolytic Transfusion
Reaction - AHTR
 Increased destruction of donor red cells
◦ Acute -Intravascular haemolysis
◦ Delayed -Extravascular haemolysis

 Causes for acute Hemolysis

◦ Red cell incompatibility –ABO incompatibility
◦ Accidental heating or freezing of RBC
◦ Red cells in contact with water or 5% Dextrose
◦ Bacterial contamination
◦ Administering red cells through small gauge needle
ABO incompatibility
 Mainly due to misidentification of the
patient :
◦ Most occur in emergencies, in ICU,
Operation Theaters
◦ In unconscious & anesthetized patients

 Causes
◦ Clerical errors –commonest cause
 Misidentification of patient / recipient
 Wrong samples / blood packs
◦ Technical errors
 In Grouping of patient / donor blood
 In crossmatching
Emergency
 Any febrile transfusion reaction should be
considered & managed as AHTR until proved
otherwise
 Signs & symptoms may be abolished by drugs
 Patients in coma or under GA- the early alarming
sign may be
◦ Haemoglobinurea
◦ Hypotension
◦ Uncontrollable bleeding
Management of AHTR
 Stop transfusion immediately
 Maintain an IV line
 Provide cardio respiratory support
 Maintain BP, HR and airway
 Ensure diuresis
 Collect first urine sample for haemoglobinurea
 Check the patient’s identification and the blood pack
 Supportive Therapy –O2, Elevate the foot end.
 Treat DIC – Heparin
 Treat Renal Failure - Dopamine , Diuretics
 Treat hyperkalemia, bicarbonate for acidosis
Cont….
 Active intervention (hemofiltration, peritoneal dialysis,
hemodialysis) is needed if patient develops
◦ Uraemic stupor
◦ Pulmonary oedema
◦ Hyperkalemia
 Rapidly rising blood urea, report the reaction
immediately to Blood Bank
 Record
◦ Type of reaction & Length of time
◦ Volume, type & unit number
 Send post transfusion sample of blood & remaining
blood pack with filled reaction form to the Blood bank.
 Monitor blood urea & creatinine level
 Coagulation screen to rule out DIC
Transfusion-related acute lung
injury (TRALI)
 Occurs when recipient neutrophils are activated by the
transfused product having either anti-HLA or anti-
neutrophil antibodies.
 Symptoms include fever, chills and respiratory distress

Management:
 Supportive therapy which includes intubation and

mechanical ventilation
 Any other products from the implicated donor should be

quarantined and not transfused to any patients until

TRALI is excluded.
Transfusion associated circulatory
overload - TACO
 Pulmonary edema due to volume excess or circulatory
overload
 Occurs who often have a large volume of a transfused

product over a short period of time

 Underlying cardiovascular disease

Management:
 Diuresis

 Supplementary oxygen

 Ventilatory support rarely be required

Allergic / Anaphylactic Reactions
 Mainly due to plasma proteins
 Severity is variable
 Mild –urticaria
 Severe –anaphylactoid
◦ Due to IgA deficiency
 Occurs within minutes of commencing transfusion
 Common in patients with repeated plasma component
therapy Mild –urticaria
 Clinical features are Severe / Anaphylactoid, Cough,
Respiratory distress, Bronchospasm, Nausea, vomiting,
diarrhoea, Circulatory collapse & Hypotension & shock
Allergic / Anaphylactic Reactions -
management
 Mild –slow down rate of transfusion &
administer antihistamine
 Severe -Stop the transfusion
 Adrenaline –0.5ml IM (1 : 1000)
 Antihistamine
 Treat hypotension
 Steroids –Hydrocortisone
 Prevention
◦ Transfuse at slow rate
◦ Use Leuko depleted and Irradiated blood
Febrile Non Haemolytic
Transfusion Reactions
 Due to Antibodies in recipient against Antigens of donor
platelets or WBC
◦ HLA Antigens
◦ Granulocyte specific Antigens
◦ Platelet specific Antigens
 Presence of cytokines in blood components
 More common in multi-transfused patients
 Clinical features are fever, chills, rigor, nausea,
vomiting, hypotension and shock
Febrile Non Haemolytic Transfusion
Reactions - management
 If mild :–
◦ Slow down the infusion
◦ Use Antipyretics
 If severe : –
◦ Stop transfusion
◦ Antipyretics and symptomatic treatment
 Usually reactions are self limiting
 Can be prevented by
◦ Leucoreduced / leucodepleted blood components
◦ Antipyretic cover /warm patient/ slow transfusion
Delayed Hemolytic Transfusion
Reaction
 Days or weeks after the blood transfusion
 Due to secondary immune response
 Rh or minor blood group antibodies
 Extra vascular haemolysis
 Gradual red cell destruction
 Occurs 5-10 days after transfusion
 Jaundice appears 5-7 days after transfusion
 Fall in Hemoglobin level
Actions to be taken
 In case of a transfusion reaction, a workup must be done
to rule out the possibility of a haemolytic transfusion
reaction.

 Every transfusion reaction should be reported to the

hemovigilance programme of India.

 Therefore vigilant action should be taken by the medical

staff to inform the blood bank regarding any transfusion
reaction that they have encountered.
 Filling of Reaction Form
• Vitals signs before
transfusion
• Time of initiation of
transfusion
• Time of completion of
transfusion
• Time when the reaction was
noticed
• Details of the symptoms
noticed.
• To be signed by MOIC and
send to Blood Bank.
 ANY REACTIONS ??????
• Ensure the return of any remaining
blood component, associated
intravenous fluid bags, and tubing
for possible bacteria culture or
Gram staining.
Samples Sent To Blood Bank
• One EDTA sample with 2 patient
identifiers to be sent to the blood
bank (minimum of 2 ml)

• The sample is used for :

• Repeat blood grouping
• Repeat Cross-matching
• Indirect and Direct Antiglobulin
test
Laboratory Testing Required
 One EDTA sample – for CBC and PBS
 One sample in sterile vacutainer – for LFT (Total &
Indirect bilirubin) and RFT
 Serum LDH
 Serum haptoglobin
 Urine RE/ME – for haemoglobinuria
 Chest X-ray – for chest infiltrates and signs of pulmonary
edema.
Take Home Message
 Blood transfusion always carries
potential risks for the recipient, and
should be prescribed only for conditions
with significant potential for morbidity or
mortality, that cannot be prevented or
managed effectively by other means.

 Understanding the type of reaction and

rapid management may save patient’s
life, especially in acute reactions.

 Timely reporting of these will help to

create awareness among healthcare
professionals and also to create
evidence-based recommendations.
QUESTIONS ?.......
THANK YOU

1st Oct – National

Blood Donation Day
in India (Birthday of
Dr Jai Gopal Jolly –
Father of Transfusion
Medicine in India)