Blood Transfusion

Introduction

Medicine has made significant progress in

understanding circulation in the past few
hundred years. Dr. Philip Syng Physick
carried out the first human blood
transfusion in 1795, and the first
transfusion of human blood for treating
hemorrhage happened in England in 1818
by Dr. James Blundell.
Rapid strides have been made in
understanding blood typing, blood
components, and storage since the early
1900s. This has developed into the field of
Fresh whole blood has always been thought
of as the standard for transfusion;
however, medical advancement has
allowed the efficient use of the different
components, such as packed red blood
cells (PRBCs), individual factor
concentrates, fresh frozen plasma (FFP),
platelet concentrates, and
cryoprecipitate.

Consequently, current indications for whole

blood transfusion are generally very few.
The hemoglobin in red blood cells binds

Indications
(1) Red blood cell transfusion
the American Association of Blood Banks
advise a restrictive approach for stable
patients with non-hemorrhaging anemia.
Anemia is usually defined as a hemoglobin
level of less than 13 g/dL in males and
less than 12 g/dL in females.

While currently, a more restrictive threshold

is used to determine the indication for
transfusion, typically using a cutoff of
hemoglobin less than 10 g/dL, was used,
Guidelines for the transfusion of red blood
cells (RBC) generally follow a restrictive
threshold,
1. 7 g/dL is an agreed-upon value for
asymptomatic healthy patients and also in
those with gastrointestinal (GI) bleeding
and critically ill patients.
2.The guidelines recommend a value of 8
g/dL as the threshold in patients with
coronary artery disease or those
undergoing orthopedic surgeries.
3. The guidelines and clinical trials on
transfusion requirements in critical care
(TRICC) also recommend a value of 7 g/dl
as the threshold for critically ill patients

4.Transfusion should indicated in patients

with active or acute bleeding and patients
with symptoms related to anemia (for
example, tachycardia, weakness, dyspnea
on exertion) and hemoglobin less than 8
g/dL.

While many patients experiencing active

bleeding become anemic, but anemia itself
does not become an indication for
transfusion, but severe hemorrhagic shock
is indication for transfusion (shock is the
insufficient supply of oxygen to carry out
cellular metabolism). Red cell mass
 Transfuse 1 unit of packed red cells , will
increase the hemoglobin value by 1 g/dL
and hematocrit by 3%.
The American Society of Anesthesiologists
advises transfusion at hemoglobin levels
of 6 g/dL or less (recent data show
decreased mortality with pre-anesthetic
hemoglobin greater than 8 g/dL, especially
in renal transplant patients).

(2) Fresh frozen plasma (FFP)

1.prophylaxis in non-bleeding
patients(prevent bleeding prior to an
urgent invasive procedure in patients
requiring replacement of multiple
coagulation factors).
2.indicated in bleeding patients to replace
lost coagulation factors
3.Clinical situations fulfilling this criterion
include
1) Cardiopulmonary bypass
2) Massive transfusion
3) Decompensated liver disease
4) Extracorporeal pulmonary support
4.In past FFP, combined with vitamin K,
was indicated for warfarin excess in cases
of life-threatening hemorrhage, but FFP is
rarely needed in vitamin K deficiency or
warfarin reversal because prothrombin
complex concentrate is widely available .
The exception is in the cases of
concomitant plasma volume deficit.

(3) Platelet transfusion

1. platelet deficiency or dysfunction.

2. patients with bone marrow failure

3. prophylactic platelet transfusion is

indicated when there are no other risk
factors for bleeding and platelet counts are
below 100,000 cell /µL (preventive
measure before specific procedures or to
prevent spontaneous bleeding).
4. In the case of active hemorrhage,
platelet transfusion should be done when
thrombocytopenia contributes to the
hemorrhage, The treatment is indicated in
the following bleeding cases,
1) Less than 50,000 cells/µL with severe
bleeding, including disseminated
intravascular coagulation
2) Less than 30,000 cells/µL when
bleeding is not life-threatening or
considered severe
3) Less than 100,000 cells/µL for bleeding
in the context of multiple trauma or
intracranial bleeding.

(4) Cryoprecipitate transfusion

Is indicated in,
1. Dysfibrinogenemia
2. Fibrinogen deficiency in the setting
of bleeding
3. Injury
4. Invasive procedures
5. Acute disseminated intravascular
coagulation
Contraindications
1. There are no absolute contraindications,
but some patients or their patients (in
pediatric cases) may refuse to receive
transfusions on religious grounds.
2. Whole blood transfusion is not indicated
when component-specific treatment is
available, such as using red blood cells to
treat anemia or using fresh frozen plasma
to treat coagulopathy. Whole blood
transfusion could lead to many
complications, for instance, volume
overload, which is why it is advisable to
Equipment
Blood products are transfused through
intravenous tubing with filters.
..The filters, which used to prevent
particulate debris from being
administered. However, the trapped
particulate leads to bacterial growth, and
the American Association of Blood Banks
(AABB) advises against using a filter for
more than four hours.
.. Before transfusion, the tubing should be
primed with an isotonic, calcium-free
blood-compatible solution, for example,
normal saline.

The requirements for administration

sets might vary,
.. Blood filters
.. Infusion devices, such as infusion
pumps, blood warmers, rapid infusers,
and pressure devices, can be used to
transfuse blood components.
.. A pressure infusion device may be
needed for the rapid transfusion of blood
components.
.. A blood warmer device is often needed
to prevent hypothermia in the rapid
administration of cold-blood components,
for instance, in trauma settings or
Preparation
1. Preparation for blood transfusion
involves running pre-transfusion testing
for compatibility between recipient
antibodies and donor red blood cells.
2. This involves obtaining a sample of the
recipient’s blood to send for a type and
screen.
3. The type and screen test verifies the
recipient’s blood type and also determines
if the recipient has any “unexpected”
antibodies that might cause a reaction.

The following is the list of important

steps to follow before proceeding with
blood transfusion:
1. Find current type and cross-match
2. Take a blood sample
3. Send the sample to the blood bank
4. Ensure that the blood sample has the
correct labeling with the date and timing

5. Wait for the blood bank to cross-match

and prepare the needed units
6. Obtain informed consent
7. Discuss the procedure with the patient
8. Confirm the past medical history and
Obtain Large-bore Intravenous Access
1. larger IV access
2. Each unit should be transfused within
2-4 hours
3. A second IV access should be secured
in case the patient needs additional IV
medications
4. Normal saline is the only fluid that can
be administered with blood products

Assemble Supplies
1. Y tubing with an in-line filter
2. 0.9% NaCl solution
3. warmer
Obtain Baseline Vital Signs
1. These include heart rate, temperature,
blood pressure, pulse oximeter, and
respiratory rate
2. Respiratory sounds and urine output
should also be documented
3. Notify the provider if the temperature is
more than 100 F
Obtain Blood from the Blood Bank
1. Once the blood bank notifies that the
blood is ready, its delivery from the blood
bank should be ensured
2. Packed red blood cells can only be given
one unit at a time

Technique or Treatment
Here are some of the general steps
providers should follow when carrying
out a blood transfusion:
1) Verify Blood Product
2) Explain the features of a transfusion
reaction to the patient.
3) The patient should inform the nursing
staff during the transfusion if these appear.

4) Baseline vital signs, lung sounds, urine

output, and skin color
5) Prepare the Y tubing with 0.9% NaCl
and have the blood unit ready in an
 9) Document vital signs after fifteen
minutes, then every hour, and finally, at
the end of the transfusion
10) During the transfusion, look for any
signs of transfusion reactions
11) If a reaction is suspected, stop the
transfusion immediately
12) Disconnect the blood tubing from the
patient
13) Inform the provider, stay with the
patient and assess the status
14) Document everything
15) After the transfusion, flush Y tubing
with normal saline and dispose of used Y

Complications
There are multiple complications of
blood transfusions, According to the
American Association of Blood Banks
(AABB)
including,
1. Febrile reactions are the most common
2. Infection(bacterial infections)
3. Transfusion-associated circulatory
overload
4. Allergic reaction
Transfusion-related lung injury)) 5. TRALI
6. Hepatitis C viral infection
7. Hepatitis B viral infection
Febrile Reactions
Transfusing with leukocyte-reduced blood
products, may help reduce febrile
reactions. If this occurs, the transfusion
should be stoped, and the patient
evaluated, as a hemolytic reaction can
initially appear similar and consider
performing a hemolytic or infectious
workup.
The treatment is with acetaminophen and, if
needed, diphenhydramine for symptomatic
control. After treatment and exclusion of
other causes, the transfusion can be
resumed at a slower rate

Transfusion-associated Circulatory
Overload
It is characterized by respiratory
distress secondary to cardiogenic
pulmonary edema. This reaction is most
common in patients already in a fluid-
overloaded state, such as congestive
heart failure or acute renal failure.

Diagnosis is based on symptom,

Onset within 6 to 12 hours of receiving a
transfusion, clinical evidence of fluid
overload, pulmonary edema, elevated
brain natriuretic peptide, and response to
Allergic Reaction
.. It often manifests as urticaria and pruritis
and occurs in less than 1% of transfusions.
More severe symptoms, such as
bronchospasm, wheezing, and
anaphylaxis, are rare.

.. Allergic reactions may be seen in patients

who are IgA deficient, as exposure to IgA
in donor products can cause a severe
anaphylactoid reaction. This can be
avoided by washing the plasma from the
cells prior to transfusion.

Transfusion-related Lung Injury

(TRALI)
.. This is uncommon, patients will develop
symptoms within 2 to 4 hours after
receiving a transfusion.

.. Patients will develop acute hypoxemic

respiratory distress, similar to acute
respiratory distress syndrome (ARDS),
also will have pulmonary edema, normal
CVP, without evidence of left heart failure
CVP.

.. Diagnosis is made based on a history of

Infections
.. These are potential complications.
However, the risk of infections has
decreased due to the screening of
potential donors, so hepatitis C and
human immunodeficiency virus risk are
less than 1 in a million.

.. Bacterial infection can also occur, but

does so rarely, about once in every
250,000 units of transfusion (mainly with
platelets transfusion).

Fatal Hemolysis
This is extremely rare, occurring only in 1
out of nearly 2 million transfusions. It
results from ABO incompatibility, and
the recipient’s antibodies recognize and
induce hemolysis in the donor’s
transfused cells.

Patients will develop an acute onset of

fevers and chills, low back pain, flushing,
dyspnea as well as becoming tachycardic
and going into shock.

Treatment is to stop the transfusion, leave

Post-transfusion labs
1. Retype and cross-match
2. Direct and indirect Coombs tests
3. Complete blood count (CBC)
4. Creatinine (RFT)
5. Bleeding profile …PT, and PTT (draw from
the other arm)
6. Peripheral smear
7. Haptoglobin, indirect bilirubin, LDH,
plasma-free hemoglobin
8. Urinalysis for hemoglobin

Electrolyte Abnormalities
They can also occur but rare and more
likely associated with large volume
transfusion.
..Hypocalcemia can result as citrate, an
anticoagulant in blood products(to prevent
blood from clotting), binds with calcium
(massive blood transfusion).
..Hyperkalemia can occur from the release
of potassium from cells during storage.
Higher risk in neonates and patients with
renal insufficiency.
..Hypokalemia can result from
alkalinization of the blood as citrate is
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