1. Blood Transfusion Guidelines in Clinical Practice
Salwa Hindawi
MSc, FRCPath, CTM
Medical Director of Blood Transfusion Services
KAUH
26th July2008
Dr. Salwa Hindawi

2. Introduction Blood Transfusion is not without hazards
you should weigh the risk against benefit
use of right products to the right patient at the right time
Dr. Salwa Hindawi

3. Donor Patient The risks associated with transfusion can be reduced by:
- Effective blood donor selection.
- Screening for TTI in the blood donor population.
high quality blood grouping, compatibility testing.
- Component separation and storage.
- Appropriate clinical use of blood and blood products.
- Quality assurance
Dr. Salwa Hindawi

4. Optimal additive solution
Platelets
rich
plasma
Platelets
concentrate
2nd centrifugation
Whole
blood
Whole
blood
Whole
blood
1stcentrifugation
FFP for
clinical use
Red
Cell
concentrate
Fresh plasma
FFP for
fractionation
Optimal additive solution
Cryoprecipitate
Red cells in
OAS
Dr. Salwa Hindawi

5. Plasma & Cryoprecipitate
ABO Selection of Blood Components
Patient ABO Type
RBCs, Platelets
Plasma &  Cryoprecipitate O
 O, A, B, AB A
A,O
A,AB B
B,O
B,AB AB
AB,A,B,O
Dr. Salwa Hindawi

6. Principles of Clinical Transfusion Practices
Avoid blood transfusion
Transfusion is only one part of the patient’s management.
Prevention and early diagnosis and treatment of Anemia & underlying condition
Use of alternative to transfusion.
eg. IV fluids
Good anesthetic and surgical management to minimized blood loss.
Dr. Salwa Hindawi

7. Prescribing should be based on national guidelines on the clinical use of blood taking individual patient needs into account.
Hb level should not be the sole deciding Factor Clinical evaluation is important
Dr. Salwa Hindawi

8. Consent form to be obtained from the patient before transfusion.
The clinician should record the reason for transfusion clearly.
A trained person should monitor the transfused patient and if any adverse effects occur respond immediately.
Dr. Salwa Hindawi

9. Informed consent
Patient should be informed that transfusion of blood or blood component is a possible element of the planned medical or surgical intervention
patient should be informed about the risks, benefits and available alternative
Consent form is a doctor responsibility
Dr. Salwa Hindawi

10. WHEN WE SHOULD TRANSFUSE BLOOD ? & WHAT BLOOD COMPONENT
SHOULD BE TRANSFUSED ?
Dr. Salwa Hindawi

11. TO TRANSFUSE BLOOD WHEN NECESSARY
Dr. Salwa Hindawi

12. Triggers of Component Transfusion
The lowest threshold for transfusion of components are:
Hb level of 6-7g/dl.
FFP threshold PT & PTT 1.5 times the upper limit of the normal range.
Platelet threshold of:
10 000/µl /µl for prophylactic transfusion.
Consider: Clinical judgment
Dr. Salwa Hindawi

13. Invasive or surgical procedures: 20 000/µl for BMA and Biopsy
50 000/µl for surgery, massive transfusion,
Liver cirrhosis.
/µl for surgery to brain or eye.
American Society of clinical Oncology guidline,1996&2001.
Williamson LM. Transfusion Trigger in the UK. Vox sang 2002.
AABB Technical Manual 14th ed, 2002.
Dr. Salwa Hindawi

14. Administration of blood components
Pretransfusion :
Recipient identification: The name and identification number on the patient’s identification band must be identical with the name and number attached to the unit.
Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit (if not the same as the latter) must agree.
Dr. Salwa Hindawi

15. Guidelines for blood component therapy
Indications NB: Hb should not be the sole deciding factor for transfusion.
Haemoglobin (Hb) trigger for transfusion
If there are signs or symptoms of impaired oxygen transport
Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available e.g. sickle cell disease or iron deficiency anemia
< 7 g/dL
Preoperative and for surgery associated with major blood loss.
< 7 – 8 g/dL
In a patient on chronic transfusion regimen or during marrow suppressive therapy.
May be appropriate to control anaemia-related symptoms.
< 9 g/dL
Not likely to be appropriate unless there are specific indications.
Acute blood loss >30-40% of total blood volume.
< 10 g/dL
Dr. Salwa Hindawi

16. Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age:
1. Hemoglobin <7 g/dL with low reticulocyte count and symptoms of anemia
2. Hemoglobin <10 g/dL with an infant
On <35% hood O2
On O2 by nasal cannula
On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H2O
Significant apnea or bradycardia
Significant tachycardia or tachypnea
Low weight gain
3. Hemoglobin <12 g/dL with an infant
On >35% hood O2
On CPAP/IMV with mean airway pressure 6 to 8 cm H2O
4. Hemoglobin <15 g/dL with an infant
On extracorporeal membrane oxygenation (ECMO)
Congenital cyanotic heart disease
Dr. Salwa Hindawi

17. Platelet Count trigger for transfusion
Indications
Platelet Count trigger for transfusion
As prophylaxis in bone marrow failure.
< 10 x 109/L
Bone marrow failure in presence of additional risk factors: fever, antibiotics, evidence of systemic haemostatic failure.
< 20 x 109/L
Massive haemorrhage or transfusion.
In patients undergoing surgery or invasive procedures.
Diffuse microvascular bleeding-DIC
< 50 x 109/L
Brain or eye surgery.
< 100 x 109/L
Appropriate when thrombocytopenia is considered a major contributory factor.
Any Bleeding Patient
In inherited or acquired qualitative platelete function disorders, depending on clinical features & setting.
Any platelet count
Dr. Salwa Hindawi

18. FFP trigger for transfusion
Indications
FFP trigger for transfusion
Multiple coagulation deficiencies associated with acute DIC.
Inherited deficiencies of coagulation inhibitors in patients undergoing high-risk procedures where a specific factor concentrate is unavailable.
Thrombotic thrombocytopenia purpura (plasma exchange is preferred)
Replacement of single factor deficiencies where a specific or combined factor concentrates is unavailable.
Immediate reversal of warfarin effect in the presence or potentially life-threatening bleeding when used in addition to Vitamin K & / or Factor Concentrate (Prothrombin concentrate)
The presence of bleeding and abnormal coagulation parameters following massive transfusion or cardiac bypass surgery or in patients with liver disease
PT & PTT are more than 1.5 times the upper limit of normal range
Cryoprecipitate trigger for transfusion
Congenital or acquired fibrinogen deficiency including DIC.
Hemophilia A, von Willebrand disease (if the concentrate is not available).
Factor XIII deficiency.
Fibrinogen< 1gm/L
Dr. Salwa Hindawi

19. Guidelines for routine blood leucodepletion
transfusion dependent patients
Bone marrow transplant candidates – either autologous / peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants
may be for Patients undergoing intensive chemotherapy regimens
Previous repeated febrile reactions to red blood cells
Guidelines for routine blood leucodepletion
Intrauterine transfusion (IUT) and neonates received IUT.
One week prior to stem cell collection, and for 12 months post autografting or allografting.
Hodgkin’s disease
Treatment with purine analogues (fludarabine, 2-CdA, deoxycofomycin)
Aplastic anaemia within 6 months of ATG treatment
Products obtained from close relatives or HLA matched donors.
Immunodeficiency patients: congenital or acquired
Guidelines for blood Irradiation (to prevent TAGVHD)
Dr. Salwa Hindawi

20. Maximum Surgical Blood Ordering Schedule (MSBOS)
MSBOS is a table of elective surgical procedures that lists the number of units of blood routinely cross-matched pre-operative.
The ideal value for cross matched to transfused blood, C:T ratio is 1:1 .
An acceptable value is 3:1 - 2:1 which corresponds to a blood usage of 30-50%.
Dr. Salwa Hindawi

21. Type and Screen (T & S)
an ABO and Rh type and an antibody screen and antibody identification are done when the patient is admitted.
only testing necessary if low probability of transfusion
Dr. Salwa Hindawi

22. Type and Cross (T & C)
includes an ABO and Rh type and antibody screen and antibody identification.
in addition includes a crossmatch where specific units of blood are held back for up to three days for a particular patient.
for a high probability of transfusion.
Dr. Salwa Hindawi

23. Crossmatch to Transfusion ratio (C:T ratio)
blood is used more efficiently when the number of units set aside for a particular patient (crossmatched) are actually transfused.
C:T ratio is less than 2:1
when a patient does not need blood, it is good practice to get a T& S but not a T & C
Dr. Salwa Hindawi

24. Incompatible Blood Transfusion Clinical Setting A patient, lacking compatible blood, experiencing life- threatening, rapid blood loss or hemolysis, in whom the need for blood replacement is immediate or urgent.
Dr. Salwa Hindawi

25. Rarely, facility may lack ABO compatible blood
Rarely, facility may lack ABO compatible blood * Pan-agglutinin (autoantibody) may be present * Alloantibody to high frequency antigen may be present * Alloantibodies to multiple antigens may be present
Dr. Salwa Hindawi

26. Guidelines for Transfusing Incompatible Red Blood Cells
If patient condition permits, start the transfusion slowly at one ml per minute for the first 15 minutes.
Observe the patient constantly for symptoms and signs of a reaction.
Take vital signs prior to starting transfusion, whenever a reaction is suspected or, in the absence of a reaction after first 15 minutes, after 30 minutes, and after completion of transfusion.
Dr. Salwa Hindawi

27. If there is evidence of a transfusion reaction
Symptoms include fever, pain, apprehension, chills, sweating, tachycardia, or fall in blood pressure.
STOP the transfusion immediately, maintaining the IV with 0.9% saline.
Document vital signs at least every 15 minutes throughout the reaction.
Dr. Salwa Hindawi

28. If patient condition warrants immediate transfusion:
Begin another unit of Red Blood Cells per physician order. The new unit also is likely to test as incompatible, but may be tolerated better.
If further transfusions can be delayed, follow the transfusion reaction policy and resume transfusion after evaluation is complete.
Dr. Salwa Hindawi

29. If no symptoms or signs of transfusion reaction are noted after 30 minutes
Proceed with the transfusion and monitor the patient for usual transfusion practices.
Repeat the entire process for each incompatible Red Blood Cell transfused.
Dr. Salwa Hindawi

30. Complications of Blood Transfusion
Immediate Delayed
HTR GVHD
FNTR PTP
TRALI Iron overload
Bacterial Infectious
contamination diseases
Allergic, Anaphylaxis
Dr. Salwa Hindawi

31. TRANSFUSION REACTION WORK-UP FORM
This part should be filled by the physician incharge :
Date /time : _________________________
Patient's name:_____________________
Ward : _____________________________
File number: ______________________
Number of Pregnancies/deliveries :________________
Number of previous transfusions:_______________
Diagnosis :_______________________________________________________________________________
________________________________________________________________________________________
Transfusion time discontinued :
Transfusion date/time started
Temp discontinued:
Temp started:
Reaction noted : put  if indicated and please specify time reaction started and duration:
Pruritus
Hematuria
Anxiety
Chest Pain
Pain in legs
Oliguria
Restlessness
Chills
Pain in back
Anuria
Headache
Fever
Rigor
Jaundice
Urticaria
Sweating
Bronchospasm
Shock
Pallor
Nausea
Dyspnea
Cyanosis
Erythema
Vomiting
Pulmonary edema
Precordial distress
Dr. Salwa Hindawi

32. Dr. Salwa Hindawi This part for blood transfusion services staff:
URINE APPERANCE : YELLOW  RED  DARK BROWN  TURBID 
SERUM PRE TRANSFUSION APPEARANCE: CLEAR  HEMOLYSIS  ICTERIC 
SERUM POST TRANSFUSION APPEARANCE: CLEAR  HEMOLYSIS  ICTERIC 
Blood CULTURE IF INDICATED : NEGATIVE  POSITIVE  ___________________________________
Patient’s sample and donor unit are correctly identified.  Yes  No
Amount of blood was transfused : unit # ___________ volume: ____ML unit # _________ volume: ____ML
Anti body screening CC
DCT
ABO/Rh
B cell
A1 cell
Anti-D
Anti-AB
Anti- B A
Patient sample
Sc3
Sc2
Sc1 AG 37 RT
Pre transfusion sample
Immediate post transfusion sample
2nd post transfusion sample ( if possible )
Elution result:___________________________________________________________________________
Antibody identification :____________________________________________________________________
Interp
cross match
Cross matching CC
AHG 37 IS
Pre transfusion sample and unit number:___________________
Post transfusion sample and unit number:___________________
post transfusion sample and unit number:___________________
Dr. Salwa Hindawi

33. ALTERNATIVES TO BLOOD TRANSFUSION
CRYSTALLOID SOLUTIONS
COLLOID SLOUTIONS
DRUGS: DDAVP
BLOOD SUBSTITUTES: EPO
Dr. Salwa Hindawi

34. AUTOLOGUS BLOOD TRANSFUSION
1- Preoperative Collection (PAD)
2-Acute normovolemic haemodilution (ANH).
3- Red Cell salvage
Dr. Salwa Hindawi

35. Table 1. Autologous Blood Donation
Disadvantages:
Advantages:
1.  Does not affect risk of bacterial
Contamination.
2.  Does not affect risk of ABO incompatibility
 3.  Is more costly than allogenic blood.
 4.  Results in wastage of blood not transfused. 
 5.  Increase prevalence of adverse reactions to autologous donation. 
 6. Can  subject patients to perioperative anaemia and increased likelihood of transfusion. 
1. Prevents transfusion-transmitted
disease. 
2.  Prevents red cell alloimmunization.
 3.  Supplements the blood supply.
 4.   Provides compatible blood for patients with alloantibodies. 
 5.  Prevents some adverse transfusion reaction. 
 6.  Provides reassurance to patients concerned about blood risks. 
 7.  Is acceptable to many Jehovah’s witnesses. 
Dr. Salwa Hindawi

36. Nowing is not enough we must apply. Willing is not enough we must do.
Johann Von Goethe
Dr. Salwa Hindawi

37. Thanks
Dr. Salwa Hindawi