rational use of blood

1. Blood Transfusion Guidelines in
Clinical Practice
Dr.Biplabendu Talukdar
MBBS, MD(IHBT), M.Phil(RMTS)
State Programme officer ,
State Blood Cell (under NHM),WB
19th
March 2018

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

3. 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
Donor Patient

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

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

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.

7. – Prescribing should be based onPrescribing should be based on
national guidelines on the clinical usenational guidelines on the clinical use ofof
blood taking individual patientblood taking individual patient needs intoneeds into
account.account.
– Hb level should not be the soleHb level should not be the sole
deciding Factor Clinical evaluation isdeciding Factor Clinical evaluation is
importantimportant

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.

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

10.  WHEN WE SHOULD TRANSFUSE BLOOD ?
&
WHAT BLOOD COMPONENT
SHOULD BE TRANSFUSED ?

11. TO TRANSFUSE BLOODTO TRANSFUSE BLOOD
WHENWHEN
NECESSARYNECESSARY

12.  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- 20 000/µl for prophylactic transfusion.
Consider: Clinical judgment
Triggers of ComponentTriggers of Component
TransfusionTransfusion

13. Invasive or surgical procedures:
 20 000/µl for BMA and Biopsy
 50 000/µl for surgery, massive transfusion,
Liver cirrhosis.
100 000/µl for surgery to brain or eye.
American Society of clinical Oncology guidline,1996&2001.American Society of clinical Oncology guidline,1996&2001.
Williamson LM. Transfusion Trigger in the UK. Vox sangWilliamson LM. Transfusion Trigger in the UK. Vox sang
2002.2002.
AABB Technical Manual 14AABB Technical Manual 14thth
ed, 2002.ed, 2002.

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.

15. Haemoglobin
(Hb) trigger for
transfusion
Indications NB: Hb should not be the sole deciding factor
for transfusion.
< 7 g/dL
•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 – 8 g/dL
•Preoperative and for surgery associated with major blood
loss.
< 9 g/dL
•In a patient on chronic transfusion regimen or during
marrow suppressive therapy.
•May be appropriate to control anaemia-related symptoms.
< 10 g/dL •Not likely to be appropriate unless there are specific
indications.
• Acute blood loss >30-40% of total blood volume.
Guidelines for blood component therapy

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 H2
O
•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 H2
O
4.Hemoglobin <15 g/dL with an infant
•On extracorporeal membrane oxygenation (ECMO)
•Congenital cyanotic heart disease

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

18. FFP trigger for
transfusion Indications
PT & PTT are more
than 1.5 times the
upper limit of normal
range
•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
Cryoprecipitate
trigger for
transfusion
Indications
Fibrinogen< 1gm/L •Congenital or acquired fibrinogen deficiency including DIC.
•Hemophilia A, von Willebrand disease (if the concentrate is not
available).
•Factor XIII deficiency.

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

20.  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%.
Maximum Surgical Blood OrderingMaximum Surgical Blood Ordering
Schedule (MSBOSSchedule (MSBOS))

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

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.

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

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.

25. 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

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.

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.

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.

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.

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

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

32. 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
Patient
sample
An
ti-
A
An
ti-
B
An
ti-
A
B
An
ti-
D
A1
cel
l
B
cel
l
ABO
/Rh
D
C
T
C
C
Anti body screening
Sc1 Sc2 Sc3
R
T
3
7
A
G
C
C
R
T
3
7
A
G
C
C
R
T
3
7
A
G
C
C
Pre transfusion
sample
Immediate post
transfusion
sample
2nd
post
transfusion
sample ( if
possible )
Elution result:___________________________________________________________________________
Antibody identification :____________________________________________________________________
Cross matching cross match Interp
Pre transfusion sample and unit
number:___________________ IS 37 AHG
C
C
Pre transfusion sample and unit
number:___________________
Post transfusion sample and unit
number:___________________
post transfusion sample and unit
number:___________________

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

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

35. Table 1. Autologous Blood Donation
Advantages:
Disadvantages:
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.
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.