Administration of Blood
Dr. MuKeSh M. DeSaI. M.D.
HaEmAtOlOgY & ImMuNoLoGy CeLl
Consultant Hematologist & Oncologist & Immunologist
Sir Harkisondas Nurrotamdas Hospital
Balbhai Nanavati Hospital
Saifee Hospital
Asian Heart Institute
Chief Division of Immunology
Prof of Pediatric Hematology & Oncology
Department of Pediatric Hematology Oncology
Bai Jerbai Wadia Hospital For Children; Mumbai.
e mail : mmdesai007@gmail.com
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.
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.
Safe transfusion practice begins with 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.
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.
Administer blood within half an hour of issue from blood bank.
½ Hour time limit is empirical and is the time taken for blood bag to reach 10 degree 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 delay in starting blood transfusion can be avoided by properly educating transfusionist.
Open system of blood e.g. saline washed RBC should be used within 24 hr.
Blood components like cryoprecipitate & FFP should be used with in 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 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.
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".
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.
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.
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.
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
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.
21 OR 20 NO. SCALP VEIN OR VENFLOW
For Pediatric transfusion, use 23 no scalp vein.
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.
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.
Massive transfusion 100 ml/minute or 1 blood bag every 3 minute as the recipient may develop hypothermia and arrythmias.
Exchange transfusion in a neonate
Cold agglutinin disease
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.
Delay in initiation of transfusion
Blood warming before initiation
Transfusion over prolonged duration.
Storage in unmonitored refrigerator.
Delay in completion.
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’t use blood from unlicensed blood bank
Don’t delay initiation of blood transfusion.
Don’t warm blood.
Don’t use routine pretransfusion 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.