Introduction
The transfusion is extremely safe today, however, the general perception that transfusions are unsafe persists thanks largely due to the HIV pandemic and risk of post-transfusion hepatitis. Today very often it is said, " The best blood is the one that you have not received." Preventable death due to wrong identification of blood still occurs and is largely occur due to human error. Ignorance among clinicians about how to transfuse blood adds further to these preventable deaths.
As a clinician, one will have to be aware of:
- 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 the 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
- 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
- Administer blood within half an hour of the issue from the blood bank.
- ½ Hour time limit is empirical and is the time taken for the blood bag to reach 10 degrees Celsius temp.
- No blood bank will accept blood back if it has reached 10-degree temp and it has to be discarded.
- Non-medical reasons for the delay in starting blood transfusion can be avoided by properly educating transfusions.
- Open system of blood e.g. saline washed RBC should be used within 24 hr.
- Blood components like cryoprecipitate & FFP should be used within 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 the blood of 0 to 4 degree Celsius cannot be assured and gives a false sense of security. This is a common practice in small nursing homes and ICCU and surgical theaters 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
- 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
- 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 change to occur in case of a transfusion reaction.
Care During Transfusion
- First half an hour is crucial.
- Risk of catastrophic event like ABO hemolytic reaction and anaphylactic reaction is maximum in the first ½ hr.
- Risk declines sharply after ½ hr.
- Record vital signs every 15 minutes.
- Increase rate of infusion to required rate.
- Observe through out transfusion.
Rate of Infusion of Blood
- First ½ hr is slow.
- If no reaction, increase the rate depending on recipient's haemodynamic status.
- If haemodynamically stable, transfuse over 2 hours.
- 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
- 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)
Blood Transfusion Filters
- All blood component must be infused using filters.
- Filters remove microscopic clots, cellular debris & undesirable particles.
- Blood components like cryoprecipitate, platelets, FFP should also be infused using blood transfusion sets with filters.
- Purified factor VIII, IX are provided by needles with inline filters
- Standard blood transfusion filter size is 170-260 micron.
- Microaggregate filter pore size is 20 -40 micron.
- For routine transfusion, microaggregate filter is not necessary.
- Microaggregate filter removes decomposed platelets, WBC and fibrin generated after 5 days of storage of blood with sizes of 20-160 micron which are pathologically implicated in ARDS, TRALI (Transfusion related acute lung injury) and pulmonary dysfunction.
- Microaggregate filters are routinely used for transfusion in cardiovascular surgery e.g. CABG
- Microaggregate filters are inappropriate to use in massive transfusion because it slows the rate of transfusion.
- Microaggregate filters in pediatric cases can result in hemolysis.
Needles
- 21 OR 20 NO. SCALP VEIN OR VENFLOW
- For Pediatric transfusion, use 23 no scalp vein
If Blood Flow Rate Is Slow
- Elevate blood container.
- Check patency of needle and size.
- Examine filter for excess debris.
- Examine blood bag for presence of clot.
- Add normal saline 50 to 100 cc
Blood Warming
- For routine blood transfusion blood warming is NOT necessary.
- As blood flows drop by drop, it attains body temperature quickly.
- Infusion of blood without warming is NOT responsible for febrile reactions or any other transfusion reaction.
- Blood warming results in increased metabolism, reduced 2,3 DPG and increased risk of bacterial overgrowth.
INDICATIONS for Blood warming:
- Massive transfusion 100 ml/minute or 1 blood bag every 3 minute as the recipient may develop hypothermia and arrhythmias.
- Exchange transfusion in a neonate.
- Cold agglutinin disease
BLOOD WARMING:
- The whole blood bag should not be warmed.
- Microwave should not be used for blood warming.
- Blood warmers are available which warm the blood as it is flowing through the tubing.
- While thawing FFP or warming blood the outlet port of the bag should be protected.
BLOOD WARMING occurs in clinical practice because of:
- Delay in initiation of transfusion
- Blood warming before initiation
- Transfusion over prolonged duration.
- Storage in unmonitored refrigerator.
- Delay in completion.
*Addition of Drugs and Medications to Blood Bags is Prohibited:
- Exception: Normal saline, 5% albumin.
- Addition of drugs may cause a change in the blood e.g. Ringer's lactate results in clotting of blood and is contraindicated along with blood; 5% dextrose results in hemolysis.
- Changes in drug can occur because of pH and ionic molecular constituent.
- In case a reaction occurs it would be impossible to ascertain who was responsible for the reaction.
Don'ts For Blood Transfusion
- Don't use blood from unlicensed blood bank.
- Don't delay initiation of blood transfusion.
- Don't warm blood.
- Don't use routine pre-transfusion 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
Any adverse reaction that occurs during the administration of blood and blood component must be considered as a transfusion reaction unless proved otherwise. Transfusion reactions occur in 7% to 10% of all recipients of blood or blood components. Fortunately, the majority of them are minor reactions. 10% of these reactions are hemolytic and 90% of these are non-hemolytic reactions. The incidence of ABO mismatch blood being infused is 1: 30,000 blood bag. 1 out of 10 ABO mismatch transfusion is fatal.
Transfusion reactions may be divided as follows:
Acute (<24 hrs):
Immunologic: Hemolytic transfusion reaction Febrile non-hemolytic transfusion reaction Allergic Anaphylaxis TRALI
| Etiology ABO incompatibility Cytokines, anti-leukocyte antibodies Antibodies to plasma proteins Antibodies to IgA Antibodies to leucocytes or complement activation
|
Non-immunologic: Marked fever with shock Atypical reaction with hypotension Congestive Heart failure Air embolism Hypocalcaemia Hypothermia Hypokalemia and hyperkalemia.
| Bacterial contamination Associated with ACE inhibitors Volume overload Air infusion via line Citrate toxicity Rapid infusion of cold blood Red cell storage
|
Delayed adverse reaction to transfusion (> 24 hrs):
|
Immunologic: Alloimmunization to RBC, WBC, platelets Hemolytic TAGvHD Post Transfusion Purpura Immunomodulation
| Etiology: Exposure to antigen of donor origin-Plasma protein, HLA Anamnestic antibody to RBC antigen Engraftment of transfused functional lymphocytes Antiplatelet antibodies not well understood
|
Nonimmunologic: Iron overload Transfusion transmitted diseases
|
multiple transfusion. Hepatitis, HIV, cytomegalovirus, etc |