1. Blood Transfusion tutorial
MBBS Curriculum
IOD II
Dr Dupe Elebute
Consultant
Department of Haematology

2. Case Presentation 1
A patient with Aplastic Anaemia arrived for her twice weekly infusion of platelets
On receiving the platelets from the blood bank and checking the unit the product appeared to be “greenish” in colour
The unit was checked and was correct for this particular patient
15 minutes into the transfusion she collapsed and the transfusion was stopped
What is the diagnosis?
What actions would you take?

3. Case 1: Actions taken Platelet transfusion stopped immediately ABC
Given hydrocortisone 100mg IV and piriton 10mg IV
Started on IV broad-spectrum antibiotics
Platelets returned to the lab and cultured
Culture of platelets: Bacillus Cereus

4. Case 1: Actions taken
Returned unit to NBS; unit re-cultured and also grew Bacillus Cereus
NBS recalled the 3 donors of the platelet pool and swabbed the donors’ arms
One of the swabs also grew Bacillus Cereus
NBS reviewed technique for swabbing of arms of donors and implemented new national guidelines

5. Acute transfusion reactions
Acute haemolytic transfusion reaction due to
ABO incompatible blood or bacterial contamination
difficult to differentiate clinically
causes:
acute intravascular haemolysis
shock
acute renal failure
DIC
extremely serious, can be fatal

6. Management of AHTR A medical emergency: Stop transfusion immediately
Keep line open with N/Saline using new giving set
Monitor pulse, BP, temp
Call member of medical staff
Check identity of patient against blood bag
Take urgent blood samples:
FBC, cross-match, U & Es, clotting screen, blood cultures
Save any urine
Send blood unit back to the blood bank

7. Febrile non-haemolytic transfusion reactions
‘Allergic’ reaction caused by white cells in
blood bag
Symptoms:
Fever
Urticaria
Anaphylaxis (rarely)
Management: Hydrocortisone and Piriton
Very rare in UK now following universal leuco-depletion of red cells (vCJD initiative)

8. Case Presentation 2 A 45 year old was admitted for hysterectomy
Normal blood count preoperatively
Received three units of blood perioperatively
Pale and jaundiced on the 10 day postoperatively
What is the diagnosis?
What haematological tests would you request?

9. Delayed haemolytic transfusion reactions
Due to secondary immune response following re-
exposure to a red cell antigen
Patient previously sensitised to a red cell antigen by transfusion or pregnancy
Antibody not detected on routine screening for X-match
Patient given transfusion with blood containing same antigen
Provokes an anamnestic (secondary immune) response
Within days, antibody level rises and transfused red cells removed from circulation

10. Delayed transfusion reactions: 2
Occurs 24hr after transfusion (7-10 days)
Causes extravascular haemolysis
Red cells destroyed in liver, spleen; occurs slowly
Few clinical signs: fever, anaemia, jaundice
Investigations:
Coomb’s test positive
Re-testing of patient’s serum will now detect antibody
In future, patient must be transfused with antigen negative blood

11. Case Presentation 3 A woman is bleeding profusely post partum
On examination, she is agitated, sweating and cold to the touch
What would you do first ?
What baseline haematological tests are indicated ?
How should she be managed ?

12. Massive blood loss Medical emergency
Loss of one blood volume within 24 hour
50% blood volume loss within 3 hours
Rate of blood loss  150ml/min
Any blood loss >2L (SGH)
Usually occurs in A&E, operating theatre or obstetric department
High morbidity & mortality

13. Massive Blood Loss (2) Ensure adequate venous access
Attempt to maintain blood volume with saline,
plasma expanders
‘Flying squad’ blood (O Rh Neg, CMV neg) available if blood required in 15 minutes

14. Complications of Massive Transfusion
Hypothermia  acidosis
Hyperkalaemia: K+ leaks out of red cells during storage
Citrate toxicity: red blood cells kept in citrate plus additive solution (SAG-M)
Hypocalcaemia: Ca2+ ions bound by citrate
Depletion of platelets and coagulation factors
Fluid overload  acute respiratory distress syndrome (ARDS)

15. Case 3 A health care assistant collected a unit of blood from
the blood bank fridge without taking any means of identification
The checking of the unit was undertaken only with the compatibility slip and the blood unit at the nurses station
The patient was blood group B
Within 15 minutes of the transfusion the patient had received 50 mls of Group A blood
Within 30 minutes the patient became unwell
What errors have occurred in the transfusion process?

16. Case 3: errors that occurred
HCA took no means of formal identification to collect the unit of blood
No other means of identification was taken for checking the unit of blood
No bedside check took place
(must be done by 2 trained staff)
No checking of the wrist band

17. 1:3 ABO incompatible 1:10 fatal Errors in transfusion
Wrong blood to wrong patient
1:3 ABO incompatible
1:10 fatal
Fatal errors in approx 1: (UK, USA)
Non-fatal 1:12000 O †
B blood  :

19. Further reading Essential Haematology ABC of Transfusion (BMJ books)
HMSO Handbook of Transfusion Medicine
SGH handbook of blood transfusion
policies and procedures