1. Blood Transfusion Dr Dupe Elebute MD, MRCP, MRCPath
Consultant in Haematology and Transfusion Medicine

2. Objectives Blood components Ordering blood & MSBOS
Risks of blood therapy
Adverse reactions
Massive blood transfusion

3. Blood - Where From? Use carefully! Human source - no synthetics yet
- not risk free
Scarce resource
1 donor can give 1 unit every 4 months
Need 10,000 units of blood/day in U.K.
Use carefully!

4. When To Use Blood? Balance between benefits vs risks Doctor’s decision
Definite indication must be recorded in the patient’s medical records
Correct anaemia pre-operatively
Try to reduce unnecessary exposure to blood products

6. Blood components Unpaid, volunteer donor Pooled products
Single donations
by apheresis

7. Blood donors
Medical selection process to protect both recipients and donors
Minimum age: 17 years
Maximum age: 70 years (60 for first time donations)
Donor deferral system

8. Blood donations Tested in the UK for: Hepatitis B, C HIV-I, II
Syphilis
ABO and RhD blood group
?vCJD  universal leucodepletion

9. Blood components available in the UK

10. Preparation of Blood Components

11. Blood components issued in the UK (2001-2002)
Red cells ,683,463
Platelets ,451
Fresh frozen plasma ,236
Cryoprecipitate ,253
TOTAL ,408,402

12. Red cells Whole blood (450ml; PCV 0.35-0.45)
<1% used as ‘whole blood’ in UK
Deficient in labile clotting factors
Packed red cells (350ml; PCV )
Stored at 2-6 ºC for up to 35 days
1 unit -> Hb rise by 1g/dl in adult
New Hb trigger of 8g/dl

13. White cells (granulocytes)
Very rarely used in the UK
Only for severe infections in neutropenic patients unresponsive to antibiotics/antifungal Rx
Transfused as ‘buffy coats’ or collected by apheresis

14. Platelet concentrates
Adult single dose (1 pool): 300 x 109/L
Stored at room temperature for up to 5 days (kept agitated)
Obtained in two ways:
Pooled platelets from 4-5 single donations
Single donor platelets collected by cell separator machine (apheresis)

15. Platelet concentrates (2)
Indications for platelet transfusions:
Bone marrow failure (aplastic anaemia)
Post chemotherapy, BMT
Massive blood transfusion (dilutional)
Platelet dysfunction (CABG, aspirin)

16. Fresh frozen plasma (FFP)
Stored frozen at –30ºC for up to 1 yr
Not routinely virally inactivated in UK
To be sourced from USA (volunteer, non-transfused male donors)
Provides replacement for most coagulation factors
Methylene blue FFP for neonates and children born after 1st January 1996

17. Fresh Frozen Plasma (2) Essential to give adequate volume
Dose: 12-15ml/kg
ABO compatible
Definite indications only:
Massive blood transfusion
DIC
Coagulation defect with no available factor concentrate

18. Cryoprecipitate
Separated by freezing FFP, allowing it to thaw to 4-8ºC
Re-frozen & stored at –30ºC for up to 1 yr
Enriched with FVIII, vWF and fibrinogen
Indications:
DIC
Fibrinogen deficiency

19. Plasma products Blood products derived by fractionation of plasma:
Albumin
Factor VIII concentrate
Factor IX concentrate
Human Ig

20. Ordering blood Can only be done by a registered medical doctor
Weigh up advantages vs risks!
Consider alternatives
Take blood sample for ‘group & screen’
ABO and RhD group
Screen for antibodies

21. ABO Blood Groups † O
 B blood:

22. RhD Group Antibody

24. Blood sampling Label request form with: Label sample bottle at bedside
Patient’s surname
Patients first name(s)
Date of birth (not age)
Hospital number (or A&E number)
Label sample bottle at bedside
Addressograph labels must not be used

25. Patient identification
Positively identify conscious patient by asking him/her to state their name and date of birth
Check information against patient’s identification wrist band

26. Record in hospital notes
Reason for blood transfusion
Blood loss
Nature of surgery
Pre-transfusion Hb
Number of units to be transfused
Planned date (and time) of transfusion

27. Maximum Blood Order Schedule
Pre-operative schedule of units to be cross-matched for each surgical procedure
Clear guidelines in Transfusion handbook
Blood sample still required 24 hours pre-op to check for antibodies
Does not apply to emergencies; acute bleeding; patient known to have red cell antibodies

28. Risks of blood transfusion
Infections: - hepatitis B, C
- HIV I & II
- bacteria
- protozoa (malaria)
- vCJD (?)
Transfusion reactions
Immunological reactions
Getting the wrong blood!

29. Overview of 478 cases
from SHOT report

30. Distribution of errors (n=552)
from SHOT report

31. Transfusing blood Inform patient! Indication Benefits Risks
Alternatives

32. Transfusing blood (2) Check blood!!
A. Check blood pack against patient’s wrist band
B. Check blood pack against pink blood bank form

33. The final check! Must be done at the bedside
Must be done by TWO people
Must NOT be done by untrained staff
If any discrepancy is found:
Do NOT transfuse blood
Inform blood bank immediately

34. Adverse effects of transfusion
Immunological reactions:
Immediate (ABO incompatibility, TRALI)
Delayed (DHTR, PTP, GvHD)
Non-immunological:
Immediate (Bacterial, fluid overload)
Delayed (e.g. viral infections, malaria)

35. Transfusion Reactions
Acute haemolytic:
Incompatible blood; can be fatal
Febrile non-haemolytic:
Due to cytokines from transfused WBCs
Acute bacterial infection
Allergic/urticarial

36. Transfusion Reactions (2)
Fever >38ºC
Rash
Rigors
Acute haemolytic specific:
Hypotension, loin pain, dark urine
Febrile non-haemolytic specific:
Urticaria, pruritis

37. Transfusion Reactions (3)
STOP the transfusion (spigot off)
Using a new giving set, keep line open with normal saline
Check I.D of patient, bag and cross-match form
Refer to handbook for further management

38. Massive blood loss Any blood loss >2L (SGH) Medical emergency
Usually occurs in A&E, operating theatre or obstetric department
High morbidity & mortality from:
Underlying cause of haemorrhage
Pre-existing disease (liver, renal)
Complications of massive blood transfusion

39. Massive Blood Loss (2) Ensure adequate venous access
Attempt to maintain blood volume with saline/plasma expanders
Inform blood bank
Send 2 group & X-match samples
If ‘flying squad’ blood used, inform BB

40. Massive Blood Loss (3) Call Blood Bank for : “Code Red”
“Code Blue” - Obstetric patients
Necessary blood products issued automatically
Haematology SpR will co-ordinate

41. Code Red Procedure Blood components issued: First Stage 6 units blood
1 litre FFP
2 pools platelets

42. Code Red Procedure (2) Second Stage 6 units blood
10 units cryo if fibrinogen <0.8g/l
2 pools platelets if count <100 x 109/L
Send blood for repeat FBC, chemistry, coagulation screen

43. Complications of Massive Tx
Hypothermia
Hypokalaemia
Hypocalcaemia
Acidosis
ARDS
Monitor U & Es Calcium, arterial pH
ECG, CXR