CLINICAL ASPECTS

BLOOD TRANSFUSION

Prof. dr. C. Suharti ,SpPD, KHOM, PhD, FINASIM

2017
 INTRODUCTION

• Transfusion of blood & blood components: most

common medical procedures
• The decision to transfuse or not to transfuse is a
complex decisions.
• No medical intervention is without risks; but these
risks should be offset by benefits.
 Component storage
Product Storage Storage Comments
temperature time
Red blood cells 1-60C 42 days
Platelet 20-240C 5 days With continues,
(pooled, gentle agitation
apharesis)
Plasma FFP, ≤ (-180C) 12 months after thawing
1-60C for 24 hrs
Cryoprecipitate ≤ (-180C) 12 months after thawing
20-240C for 46 hrs
if not pooled or 4
hrs if pooled
DSM 2011 Transfusion Medicine Manual.
 Testing on Donated blood

Blood is tested to identify:

o Blood type (ABO & Rh)
o Red blood cell antibodies
o Viruses (Hepatitis B/C, HIV)
INDICATIONS BLOOD COMPONENT
TRANSFUSION
 Indication for Blood Transfusion

• To increase the oxygen capacity of blood by

giving red cells
• To restore the blood volume to maintain
effective tissue perfusion
• To replace platelets, coagulation factors and
other plasma proteins
 Time limits for transfusion

• There is a risk of bacterial proliferation or loss of

function in blood products one they have been
remove from the correct storage condition

• Transfusion should be completed within a maximum

period of 4 hrs after removal from the blood fridge
(discard the unit if this period is exceeded)
 Duration times limits for transfusion
Blood products Start transfusion Complete
transfusion
Whole blood/PRBC Within 30 minutes ≤ 4hours
of removing from
refrigerator
Platelet concentrate immediately Within 30 minutes
FFP As soon as possible Within 30 minutes
Cryoprecpitate As soon as possible Within 30 minutes
 Warming blood

Transfusion rate >100ml/min of cold blood may be

contributing factor in cardiac arrest.
Warmed blood is commonly required in:
▪ Large volume rapid transfusions: for adults
>50ml/kg/hr
▪ Patients with clinical significant cold agglutinin
Use of medication at time transfusion

• It is not recommended to routinely use pre-

medication (anti-histamines, steroid or other
medication before transfusion
• This may mask or delay the signs and
symptoms of an acute transfusion reaction,
therefore delay recognition and action to stop
the transfusion
Addition of medicine or other fluids with blood
and blood components
• Medicine or other fluids should never be
infused within the same line of blood or blood
components (except for NS when the flow is
slow due to increase haematocrit or to
prepare WRC)
• Use a separate IV line if an iv fluid has to be
given at the same time as blood transfusion.

NS, normal saline; WRC, washed red cell

 Fresh blood
Fresh blood: stored blood less than 7 days (to avoid
biochemical overload)
Indication:
▪ Renal and liver dysfunction
▪ Massive blood transfusion
▪ Patients with raised plasma potassium (extensive
burns, iv hemolysis
Disadvantages of using blood that has not been
stored between +20C and +60C
Increased risk of disease transmission:
• Intracellular pathogens (CMV, HTLV) survive in
leukocytes present in the fresh blood
• Syphilis transmission: Treponema should not
survive >96 hrs in stored blood
• Malaria transmission: malaria parasite should
not survive >7 hours stored blood.

CMV, cytomegalovirus; HTLV, human T lymphocyte virus

 Red Blood Cells

RBC description:
▪ A unit of RBC: volume 240-340 ml; hematocrit of
0.54-0.68
▪ LR (leuko-reduction): a filtering process, remove
WBC

RBC contraindication:
▪ When anemia can be corrected with specific
medications: iron, B12, Folic acid, erythropoietin
etc.
 BLOOD & COMPONENTS: INDICATIONS,
COMPATIBILITY AND ADMINISTRATION OVERVIEW

Red Blood Cells (RBC):

▪ Indication: anemia with impaired oxygen delivery
▪ Compatibility: ABO and Rh: must be compatible
▪ Administration:
o Standard blood filter (170-260 micrometers) (if available)
o Rate is: 1 mL/min or 50 mL/hour for first 15 min, unless
urgent replacement is required.
o One unit usually takes 1.5-2 hours to infuse, but may be
infused over up to 4 hours in volume sensitive patients.
Triggers for transfusion of red blood cells

Hemoglobin Patient population

level
< 7 g/dL Nonbleeding medical and surgical inpatients
< 8 g/dL Inpatients with active acute coronary
syndrome
<10 g/dL Inpatients being treated for sepsis during the
first 6 hours of resuscitation

Szczepiorkowski ZM and Dunba NM. Transfusion guidelines: when to transfuse.

ASH educational book 2013.
 BLOOD & COMPONENTS: INDICATIONS,
COMPATIBILITY AND ADMINISTRATION OVERVIEW

Pooled Platelets (PLT) ; Apheresis (APLT)

▪ Indication: Treatment/ prevention of bleeding in patients
with decreased or dysfunctional platelets.
▪ Compatibility:
o Preferred ABO and Rh compatible with donor plasma
▪ Administration:
o Standard blood filter (170-260 micrometers) (if available)
o Administer as rapidly as tolerated (1 bag per 20 minutes
average in adults)
 Triggers for transfusion of platelets

Platelet Patient population

concentration
<5000/μL All patients who are not bleeding and critically
stable
<10.000/μL Patients with fever(≥380C) or recent
hemorrhage
<20.000/μL Patients receiving heparin, has coagulopathy,
or has an anatomic lesions that is likely to
bleed or is an outpatients
 Triggers for transfusion of platelets
Platelet Patient population
concentration
<50.000/μL Patients who are actively bleeding or who will
undergo invasive procedure within the next 4
hours.
<100.000/μL Neurosurgical patients
▪ There is no trigger for patients with: dysfunctional platelets
due to underlying platelet function .
▪ For the common bedside procedures: a central line placement,
lumbar puncture, bone marrow biopsy, the threshold between
20.000 and 50.000/μL
Szczepiorkowski ZM and Dunba NM. Transfusion guidelines: when to transfuse.
ASH educational book 2013.
 BLOOD & COMPONENTS: INDICATIONS,
COMPATIBILITY AND ADMINISTRATION OVERVIEW

Plasma (FP)
▪ Indication:
o Multiple clotting factor replacement
o Exchange transfusion
o Therapeutic apheresis
▪ Compatibility:
o Must be ABO compatible
o Confirmed blood group required
o Rh need not be considered
▪ Administration:
o Standard blood filter (170-260 micrometers) (if available)
o Transfuse as rapidly as clinically tolerate
 Plasma transfusion

• Dosis: 10-20 ml/kg BW

• Once thawed, the product must be transfused
within 24 hours or be relabelled as “thawed
plasma” to allow refrigerated storage up to 5
days.
Triggers for transfusion of fresh frozen plasma

INR results Patient population

>1.5 Neurosurgical patients

>2.0 Patients who will undergo invasive procedure
Undefined Trauma patients

Szczepiorkowski ZM and Dunba NM. Transfusion guidelines: when to transfuse.

ASH educational book 2013.
 Cryoprecipitate (Cryo)
Cryo Description:
▪ Cryoprecipitate is prepared from slowly thawed FP that is
centrifuged to separate the insoluble cryoprecipitate from
the plasma. The insoluble cryoprecipitate is refrozen.

▪ On average, each unit of cryoprecipitate contains at least 150

mg of fibrinogen in 5-15 millilitres of plasma.
 BLOOD & COMPONENTS: INDICATIONS,
COMPATIBILITY AND ADMINISTRATION OVERVIEW

Cryoprecipitate (Cryo)
▪ Indication:
o Bleeding due to hypofibrinogenemia or
o Dysfibrinogenemia
▪ Compatibility:
o Confirmed blood group required
o ABO compatibility preferred but not required
o Rh need not be considered
▪ Administration:
o Standard blood filter (170-260 micrometers) (if available)
o Transfuse as rapidly as clinically tolerated
TRASFUSION REACTIONS
 SUSPECTED TRANSFUSION REACTIONS OVERVIEW –
SIGNS AND SYMPTOMS
Type of Suspected Transfusion Reaction Timing of Symptoms
Reaction Signs & Symptoms
ACUTE REACTIONS (<24 hours)
Minor Allergic Pruritis, mild rash, urticaria, flushing During transfusion up
Reaction to 2-3 h from start
Febrile Non- T ≥39°C, chills, rigors, fever, Usually within first 15
Hemolytic hemoglobinuria. minutes but may be
Less common: renal failure, later
hypotension and/or tachycardia,
DIC, oliguria, oozing from IV site,
back pain, pain along infusion site
Transfusion Dyspnea, orthopnea, productive Within several hours
Associated cough with pink frothy sputum, of transfusion
Circulatory cyanosis, tachycardia, hypertension,
Overload headache
(TACO)
 SUSPECTED TRANSFUSION REACTIONS OVERVIEW –
SIGNS AND SYMPTOMS
Type of Suspected Transfusion Reaction Timing of Symptoms
Reaction Signs & Symptoms
ACUTE REACTIONS (<24 hours)
Severe Allergic Urticaria, erythema, anxiety, Severe Allergic within
/Anaphylactic respiratory distress, hypotension, 2-3 hours of start of
laryngeal/pharyngeal edema, transfusion.
bronchospasm, nausea, vomiting, Anaphylactic: Usually
dyspnea, cyanosis, tachycardia, early in transfusion (
substernal pain, loss of 1- 45 minutes) after
consciousness, cardiac arrhythmia, small volume of
cardiac arrest. product transfused
Transfusion Acute respiratory, hypoxemia, chills, Within 1-2 hours
Related fever, cyanosis, hypotension, during transfusion or
Acute Lung tachycardia, bilateral pulmonary within 6
Injury edema hours post-
(TRALI) transfusion
 SUSPECTED TRANSFUSION REACTIONS OVERVIEW –
SIGNS AND SYMPTOMS
Type of Suspected Transfusion Reaction Timing of Symptoms
Reaction Signs & Symptoms
ACUTE REACTIONS (<24 hours)
Transfusion Respiratory distress within 24 hrs of Within 24 hours of
Associated transfusion that does not meet the transfusion
Dyspnea (TAD) criteria of TRALI, TACO or allergic
reaction.
Respiratory distress not explained
by patient’s underlying condition
Hypotensive Flushing, abrupt onset of Within 5 minutes
hypotension with or without after beginning of
bradycardia, nausea, dyspnea, transfusion
urticaria
Bacterial Fever, shock, DIC, nausea, vomiting, Within 4 hours of
Contamination tachycardia, hypotension, chills, transfusion
rigors, circulatory collapse
 SUSPECTED TRANSFUSION REACTIONS OVERVIEW –
SIGNS AND SYMPTOMS
Type of Suspected Transfusion Reaction Timing of Symptoms
Reaction Signs & Symptoms
DELAYED REACTIONS (>24 hours)
Delayed Weakness, unexplained fall in Within 3-7 days post
Hemolytic post-transfusion Hb, ↑serum transfusion and up to
bilirubin, fever, weakness, 21 days post-trans.
malaise
Iron Overload Cardiomyopathy, arrhythmia, Multiple transfusions
hepatic and pancreatic failure
INFORMED CONSENT
 Informed Consent – Key Points

▪ The patient requires both verbal and written information

from the physician or authorized healthcare provider to allow
them to make an informed decision.

▪ The patient should receive written notification of transfusion

 Informed Consent – Non-Consent (Refusal)

▪ Patients have the right to not accept or refuse transfusion or

treatments involving the use of blood, blood components
and/or derivatives.
▪ Such a decision should follow an informed discussion of the
risks of this decision and the benefits of transfusion
▪ Treatment non-consents or refusals should be clearly
documented on the patient’s medical health record.
PATIENT MONITORING
 Patient Monitoring During
the Transfusion Procedure
Prior to establishment of transfusion of blood/blood
components, check:
o Informed consent has been obtained
o Patient education is complete : type of product, reason for
administration, signs and symptoms of reactions
o A visual inspection of units to be transfused is complete
o Proper patient identification has been accomplished
o Proper venous access is available
o Baseline vital signs have been taken and appropriately
documented within 30 minutes prior transfusion
o Monitoring and documentation of vital signs and patient
condition throughout the transfusion/infusion
 Management of a Transfusion Reaction

▪ All transfusion reaction investigations should be initiated

immediately.
▪ The transfusion must be stopped.
▪ Order a transfusion reaction investigation.
▪ DO NOT DISCARD component and blood infusion set or IV set
in the case of derivatives.
▪ Infuse 0.9% Normal Saline in a separate IV set to maintain
patency.
THANK YOU
 Transfusion
Reaction

Acute Delayed

Immunologic Nonimmunologic Immunologic Nonimmunologic

Hemolytic Bacterial
Hemolytic
contamination Transfusio
Febrile n
nonhemolytic Induced
Circulatory Transfusion Hemo-
overload associated GVHD siderosis
Allergic

Transfusion Physical/ Post transfusion Disease

Related acute Chemical purpura transmission
Lung injury hemolysis
(TRALI)