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. •TRANSFUSIONS USUALLY INVOLVE THE USE OF TWO SOURCES OF BLOOD – ONE’S OWN (AUTOLOGOUS TRANSFUSION) OR SOMEONE ELSE’S (ALLOGENIC TRANSFUSION). THIS IS USUALLY DONE AS A LIFE SAVING MANEUVER TO REPLACE BLOOD CELLS OR BLOOD PRODUCTS LOST THROUGH SEVERE BLEEDING. RED BLOOD CELLS. PLASMA. DURING SURGERY WHEN SEVERE BLOOD LOSS OCCURS OR TO INCREASE THE BLOOD COUNT IN AN ANAEMIC PATIENT. •BLOOD TRANSFUSIONS INVOLVES THE USE OF WHOLE BLOOD . WHITE BLOOD CELLS. CLOTTING FACTORS AND PLATELETS.introduction •BLOOD TRANSFUSION IS DEFINED AS THE PROCESS OF RECEIVING BLOOD PRODUCTS INTO ONE’S CIRCULATION INTRAVENOUSLY.

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•EACH UNIT OF BLOOD IS TESTED FOR EVIDENCE OF HEPATITIS-B. .Blood and blood products •BLOOD IS COLLECTED FROM DONORS WHO HAVE BEEN PREVIOUSLY SCREENED TO EXCLUDE ANY BLOOD OR BLOOD PRODUCTS THAT MAY HAVE THE POTENTIAL TO HARM THE PATIENT. •THE ABO AND RHESUS D BLOOD GROUP IS DETERMINED AS WELL AS THE PRESENCE OF IRREGULAR RED CELL ANTIBODIES. •THE BLOOD IS THEN PROCESSED INTO SUB-COMPONENTS. HEPATITIS-C . HUMAN IMMUNODEFICIENCY VIRUS I & II AND SYPHILIS.

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• NO FUNCTIONAL PLATELETS. •SINCE IT IS NOT STERILIZED. • 50 ml OF ANTICOAGULANT-PRESERVATIVE SOLUTION.45%. • HAEMOGLOBIN approx. CAPABLE OF TRANSMITTING ANY AGENT PRESENT IN CELLS OR PLASMA WHICH HAS NOT BEEN DETECTED BY ROUTINE SCREENING. MORE METABOLICALLY ACTIVE THAN STORED BLOOD. . 12g/ml & HAEMATOCRIT 35% . CONTAINING AN ONE UNIT OF WHOLE BLOOD CONTAINS • 450 ml OF DONOR BLOOD.WHOLE BLOOD •WHOLE BLOOD IS UNSEPARATED BLOOD ANTICOAGULANT –PRESERVATIVE SOLUTION. •HOWEVER WHOLE BLOOD TRANSFUSION HAS SIGNIFICANT ADVANTAGES OVER PACKED CELLS AS IT IS COAGULATION FACTOR RICH AND IF FRESH.

•TRANSFUSION SHOULD BE STARTED WITHIN 30 MINUTES OF REMOVAL FROM THE REFRIGERATOR AND COMPLETED WITHIN 4 HOURS OF COMMENCEMENT BECAUSE CHANGES IN THE COMPOSITION MAY OCCUR DUE TO RED CELL METABOLISM.• STORED BETWEEN +2 AND +6 DEGREES CENTIGRATE IN A BLOOD BANK REFRIGERATOR. INDICATIONS – •RED CELL REPLACEMENT HYPOVOLAEMIA •EXCHANGE TRANSFUSION CONTRAINDICATIONS – •CHRONIC ANAEMIA •INCIPIENT CARDIAC FAILURE IN ACUTE BLOOD LOSS WITH .

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•INDICATED IN REPLACEMENT OF RED CELLS IN ANAEMIC PATIENTS AND ALSO USED WITH CRYSTALLOID AND COLLOID SOLUTIONS IN ACUTE BLOOD LOSS CONDITIONS. •ONE UNIT OF PACKED RED CELLS IS APPROX.PACKED RED CELLS •PACKED RED CELLS ARE CELLS THAT ARE SPUN DOWN AND CONCENTRATED. . •IT CARRIES THE SAME INFECTION RISK AS IN WHOLE BLOOD. 330 ml AND HAS A HAEMATOCRIT OF 50-70%. •THEY ARE STORED IN A SAG-M (SALINE-ADENINE-GLUCOSEMANNITOL) SOLUTION TO INCREASE THEIR SHELF LIFE TO 5 WEEKS AT 2-6 DEGREES CENTIGRATE.

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.FRESH FROZEN PLASMA •FRESH FROZEN PLASMA IS RICH IN COAGULATION FACTORS. •IT IS SEPARATED FROM WHOLE BLOOD AND STORED AT -40 TO -50 DEGREES CENTIGRATE WITH A 2 YEAR SHELF-LIFE. •ALSO USED IN THE REPLACEMENT OF MULTIPLE COAGULATION FACTOR DEFICIENCIES LIKE LIVER DISEASE. •IT IS THE FIRST LINE THERAPY IN THE TREATMENT OF COAGULOPATHIC HAEMORRHAGE. DEPLETION OF COAGULATION FACTORS IN PATIENTS RECEIVING LARGE VOLUME TRANSFUSIONS. WARFARIN OVERDOSE. DISSEMINATED INTRAVASULAR COAGULATION AND THROMBOTIC THROMBOCYTOPENIC PURPURA.

PRECAUTIONS – •ACUTE ALLERGIC REACTIONS ARE COMMON •SEVERE LIFE THREATENING ANAPHYLACTIC REACTIONS OCCASSIONALLY OCCUR. •DOSAGE – INITIAL DOSE OF 15ml/Kg. .

•ARE USUALLY GIVEN TO PATIENTS WITH THROMBOCYTOPENIA OR THOSE WITH PLATELET DYSFUNCTION WHO ARE BLEEDING OR UNDERGOING SURGERY AND IN PATIENTS WITH BONE MARROW FAILURE. TTP.Platelets •PLATELETS ARE SUPPLIED AS A POOLED PLATELET CONCENTRATE CONTAINING ABOUT 250 X 10 9 CELLS PER LITRE. . •NOT INDICATED IN – • PATIENTS WITH ITP. •PLATELETS ARE STORED ON A SPECIAL AGITATOR AND HAVE A SHELF LIFE OF ONLY 5 DAYS. UNTREATED DIC AND IN CASES OF HYPERSPLENISM.

. • PATIENTS ON ASPIRIN THERAPY RARLELY POSE A PROBLEM BUT THOSE PATIENTS ON CLOPIDOGREL WHO ARE ACTIVELY BLEEDING AND UNDERGOING MAJOR SURGERY MUST BE GIVEN A CONTINUOUS INFUSION DURING THE COURSE OF THE PROCEDURE. SPLENOMEGALY. INCREMENT WILL BE LESS IF THERE IS ASSOCIATED SEPTICEMIA. •4-6 DONOR UNITS OF PLATELET CONCENTRATES WILL RAISE THE PLATELET COUNT BY 20-40 X 109/L. •COMPLICATION S– FEBRILE AND ALLERGIC URTICARIAL REACTIONS ARE COMMON ESPECIALLY IN PATIENTS RECEIVING MULTIPLE TRANSFUSIONS.•DOSAGE – 1 UNIT OF PLATELET CONCENTRATE /10 kg BODY WEIGHT. DIC.

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. •INDICATED IN LOW FIBRINOGEN STATES (<1g/L) OR IN CASES OF FACTOR VIII DEFICIENCY (HAEMOPHILIA-A). VON WILLEBRAND’S DISEASE AND AS A SOURCE OF FIBRINOGEN IN DISSEMINATED INTRAVASCULAR COAGULATION.CRYOPRECIPITATE •CRYOPRECIPITATE IS A SUPERNATANT PRECIPITATE OF FRESH FROZEN PLASMA AND IS RICH IN FACTOR VIII AND FIBRINOGEN. •MUST BE INFUSED WITHIN 6 HOURS. •POOLED UNITS CONTAINING 3-6 gms FIBRINOGEN IN 200-500 ml RAISES THE FIBRINOGEN LEVEL BY APPROX. •IT IS STORED AT -30 DEGREES CENTIGRATE WITH A 2 YEARS SHELF LIFE. 1g/L.

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. •GROUP A & B CONTAIN SPECIFIC ANTIGENS AND PROVOKE A REACTION IF THESE ANTIGENS ARE NOT PRESENT IN THE RECIPIENT.THIS SYSTEM CONSISTS OF 3 ALLELIC GENES A. •GROUP ‘O’ CONTAINS NO ANTIGENS TO PROVOKE A REACTION IN THE RECIPIENT AND HENCE CALLED ‘AMORPHS’. •ABO SYSTEM-THESE ARE STRONGLY ANTIGENIC AND ARE ASSOCIATED WITH NATURALLY OCCURING ANTIBODIES IN THE SERUM. •TWO GROUPS OF ANTIGENS ARE OF MAJOR IMPORTANCE IN MEDICAL PRACTICE – THE ABO AND THE RHESUS SYSTEMS.B & O.BLOOD GROUPS AND CROSS-MATCHING •HUMAN RED BLOOD CELLS HAVE MANY DIFFERENT ANTIGENS ON THEIR CELL SURFACE.

THE RHESUS D ANTIGEN IS STRONGLY ANTIGENIC AND IS PRESENT IN APPROXIMATELY 85% OF THE POPULATION. . •RHESUS SYSTEM.•THEREFORE. ANTIBODIES TO THE ‘D’ ANTIGEN ARE NATURALLY NOT PRESENT IN THE REMAINING 15% OF THE INDIVIDUALS BUT THEIR FORMATION MAY BE STIMULATED BY THE TRANSFUSION OF RH’+’ RED CELLS OR THEY MAY BE ACQUIRED DURING DELIVERY OF A RH-D-POSITIVE BABY LEADING TO HAEMOLYTIC DISEASE OF THE NEWBORN IN A SUBSEQUENT PREGNANCY. BLOOD GROUP ‘O’ IS CONSIDERED AS THE UNIVERSAL DONOR AS IT HAS NO ANTIGENS TO PROVOKE A REACTION AND ‘AB’ BLOOD TYPE IS CONSIDERED AS THE UNIVERSAL RECIPIENTS AS THEY HAVE NO CIRCULATING ANTIBODIES TO THEM.

MAKING THE DECISION FOR BLOOD TRANSFUSION .

•THE DECISION TO TRANSFUSE BLOOD OR BLOOD PRODUCTS SHOULD ALWAYS BE BASED ON A CAREFUL ASSESSMENT OF CLINICAL AND LABORATORY INDICATIONS THAT TRANFUSION IS NECESSARY TO SAVE LIFE OR PREVENT SIGNIFICANT MORBIDITY. INAPPROPRIATE USE CAN ENDANGER LIFE.•IF USED CORRECTLY. . BLOOD TRANSFUSION CAN BE LIFE-SAVING.

anticoagulants •Repeat full blood count •Consider drugs to reduce bleeding (such as aprotinin) . •Consider autologous blood deposit •Consider erythropoietin to boost haemoglobin concentration •Treat iron or folate deficiency •Stop aspirin prophylaxis if possible •Day of admission •Check if taking aspirin. non-steroidal anti-inflammatory drugs.minimising the need for blood transfusion •Preoperative planning•History and examination including surgical or bleeding history •Full blood count. blood chemistry. coagulation.

During surgery •Be prepared for longer duration to secure haemostasis •Consider hypotensive surgery if appropriate •Avoid hypothermia—give all fluids through a warmer •Consider fibrin glues and sealants Postoperative care •Accept lower postoperative haemoglobin concentration •Accept transfusions of just one unit of blood. to exceed transfusion trigger •Use continuous face mask oxygen if patient has low haemoglobin concentration •Prescribe iron and folic acid routinely •Consider Tranexamic acid .

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TRAUMATIC INJURIES TO THE CHEST. PELVIS. RUPTURED UTERUS. •ASSESSMENT OF ANAEMIA – CLINICALLY FROM THE TONGUE. PERIPHERAL PULSES. VARICEAL BLEEDING.ECTOPIC PREGNANCY. •CARDIORESPIRATORY STATE AND TISSUE OXYGENATION – BP. CONTINUING HAEMOLYSIS. NAILS AND FROM LABORATORY ASSESSMENT OF THE HAEMOGLOBIN LEVEL OR HAEMATOCRIT. ANTEPARTUM HAEMORRHAGE . PALMS. URINE OUTPUT. . RED CELL DESTRUCTION AS IN MALARIA. CAPILLARY REFILL TIME. •ANTICIPATED SURGERY WHERE POST-OPERATIVE BLOOD LOSS IS HIGHLY PROBABLE . SPLEEN. •INTERNAL BLEEDING –Eg. SEPSIS.•EXTERNAL BLEEDING & MEDICAL CONDITIONS LIKE THALASSEMIA. LUNGS. PULSE. DISSEMINATED INTRAVASCULAR COAGULATION. TEMPERATURE. EYES. CARDIAC FAILURE. RESPIRATORY RATE. CONTINUOUS BLEEDING OR LIKELIHOOD OF RECURRENCE OF BLEEDING.

RUPTURED UTERUS. ABRUPTIO PLACENTAE. RETAINED PRODUCTS OF CONCEPTION. RETAINED PRODUCTS OF CONCEPTION. TISSUE DAMAGE FOLLOWING OBSTRUCTED LABOUR. .CAUSES OF ACUTE BLOOD LOSS IN AN OBSTETRIC PATIENT •FETAL LOSS IN PREGNANCY – INCOMPLETE ABORTION. PRE-ECLAMPSIA. ABDOMINAL. •POST-PARTUM HAEMORRHAGE – UTERINE ATONY. •TRAUMATIC LESIONS – EPISIOTOMY. SEPTIC ABORTION. •ECTOPIC PREGNANCY – TUBAL. •ANTEPARTUM HAEMORRHAGE – PLACENTA PREVIA. INDUCED ABORTION. PUERPERAL SEPSIS. VASA PRAEVIA. AMNIOTIC FLUID EMBOLISM. PERINEAL OR CERVICAL LACERATIONS. RUPTURED UTERUS. TRAUMATIC LESIONS. ABRUPTIO PLACENTAE. BREAKDOWN OF UTERINE WOUND AFTER CAESAREAN SECTION. •DISSEMINATED INTRAVASCULAR COAGULATION INDUCED BY – IUFD.

PERI-OPERATIVE RED BLOOD CELL TRANSFUSION CRITERIA HAEMOGLOBIN LEVEL g/dl INDICATION <6 Probably will benefit from transfusion Transfusion unlikely to be of benefit in the absence of bleeding or impending surgery No indication for transfusion 6-8 >8 .

0 – 8.0g/dl + Established or incipient cardiac failure. PPH.Who Transfusion guidelines for chronic anaemia during pregnancy DURATION OF PREGNANCY HAEMOGLOBIN LEVEL CONSIDER IF- <36 WEEKS 5. Clinical evidence of hypoxia.Confirm blood Elective CS Planned + group.0 g/dl + Above mentioned conditions ELECTIVE CAESAREAN SECTION 8. >36 WEEKS 6. <8. Preexisting heart disease.0 g/dl OR LESS Hb 6. Save freshly taken History of APH.0 g/dl. serum for cross-matching.0 g/dl or LESS EVEN WITHOUT CLINICAL SIGNS OF CARDIAC FAILURE OR HYPOXIA Hb 5. Previous CS. Pneumonia or any serious bacterial infections.0-7. .0 g/dl – 2 Units of blood should be cross-matched and available.0-10.

ESTIMATING BLOOD LOSS •IN ORDER TO MAINTAIN BLOOD VOLUME ACCURATELY. 1. BLOOD VOLUME NEONATES 85-90ml/kg Body Weight CHILDREN 80ml/kg Body Weight ADULTS 70ml/kg Body Weight Example: An adult weighing 60 kgs would have a blood volume equal to 70x60. . 2. Weigh the ungraduated drains or suction bottles and subtract their empty weight. which is 4200 ml. IT IS ESSENTIAL TO CONTINUALLY ASSESS SURGICAL BLOOD LOSS THROUGHOUT THE PROCEDURE. Weigh the blood soaked swabs as soon as they are discarded and subtract their dry weight (1ml of blood weighs approximately 1 gm). 3. Weigh swabs while still in their dry state.

BLOOD PRESSURE. Subtract this volume from the measured blood loss to arrive at a final estimate. together with that pooling beneath the patient and onto the floor. • IN POST-OPERATIVE TRANSFUSION CASES. 5. Note the volume of any irrigation or wash out fluids that are used during surgery. HEART RATE.4. PULSE RATE. CAPILLARY REFILL TIME. COLOUR OF MUCOUS MEMBRANES. . URINE OUTPUT. Estimate blood loss into surgical drapes. RESPIRATORY RATE AND SYMPTOMS AND SIGNS OF HYPOXIA SHOULD BE CAREFULLY MONITORED. THE HAEMOGLOBIN LEVEL.

WHO ACCEPTABLE BLOOD LOSS GUIDELINE METHOD HEALTHY PATIENT AVERAGE CLINICAL CONDITION POOR CLINICAL CONDITION PERCENTAGE METHOD – Acceptable loss of blood volume 30% 20% <10% HAEMODILUTION METHOD – Lowest acceptable Haemoglobin or Haematocrit 9g/dl or 10g/dl or 11g/dl or Haematocrit Haematocrit Haematocrit = 27% = 30% =33% During surgery. Rate of blood loss. Patient’s clinical response to blood loss and fluid replacement therapy & signs indicating inadequate tissue oxygenation. . however the decision to transfuse will ultimately need to be based on the careful assessment of Volume of blood loss.

SAFE BLOOD TRANSFUSION PROCEDURES .

BLOOD GROUP OF THE BLOOD PACK. •DISCOLOURATION OF THE BLOOD PACK AND ANY SIGNS OF LEAKAGE INDICATE CONTAMINATION AND COULD CAUSE A SEVERE FATAL REACTION IF TRANSFUSED. .• EVERY HOSPITAL SHOULD HAVE WRITTEN STANDARD OPERATING PROCEDURES FOR THE ADMINISTRATION OF BLOOD PRODUCTS LIKE THE ONE WE HAVE IN OUR HOSPITAL . THE COMPATIBILITY LABEL DETERMINING THE PATIENT’S ABO AND RH-D GROUP. SIGNATURE OF THE CLINICIAN PERFORMING THE PRE-TRANSFUSION IDENTITY CHECK AND THE TRANSDUSION PROCEDURE •THE BLOOD PACK SHOULD ALWAYS BE INSPECTED FOR SIGNS OF DETERIORATION ON ARRIVAL AND BEFORE TRANSFUSION IF NOT USED IMMEDIATELY. UNIQUE DONATION NUMBER OF THE BLOOD PACK. THE INDICATION FOR TRANSFUSION. THE DATE OF COLLECTION AND THE EXPIRY DATE. PARTICULARLY FOR THE FINAL IDENTITY CHECK OF THE PATIENT.

• IN A WARM CLIMATE. FOR WHOLE BLOOD. . • FLEXIBLE PLASTIC CANNULAS SHOULD BE USED AS THEY ARE SAFER AND PRESERVE THE VEINS. CHANGE THE SET MORE FREQUENTLY AND USUALLY AFTER EVERY 4 UNITS OF BLOOD IF GIVEN WITHIN A 12 HOUR PERIOD. RED CELLS.DISPOSABLE EQUIPMENT FOR BLOOD ADMINISTRATION • CANNULAS MUST BE STERILE AND MUST NEVER BE REUSED. PLASMA & CRYOPRECIPITATE •USE A NEW STERILE BLOOD ADMINISTRATION SET CONTAINING AN INTEGRAL 170-200 micron FILTER • CHANGE THE SET AT LEAST 12 HOURLY DURING BLOOD COMPONENT INFUSION.

COLD BLOOD MAY BE A CONTRIBUTING FACTOR IN CARDIAC ARREST. . KEEPING THE PATIENT WARM IS PROBABLY MORE IMPORTANT THAN WARMING THE INFUSED BLOOD ! • WARMED BLOOD IS MOST COMMONLY REQUIRED IN LARGE VOLUME RAPID TRANSFUSIONS & EXCHANGE TRANSFUSION IN INFANTS. HOWEVER. AT INFUSION RATES >100ml/minute. •BLOOD SHOULD ONLY BE WARMED IN A BLOOD WARMER THAT HAVE A VISIBLE THERMOMETER AND AN AUDIBLE WARNING ALARM AND SHOULD BE PROPERLY MAINTAINED.• THERE IS NO EVIDENCE THAT WARMING BLOOD IS BENEFICIAL TO THE PATIENT WHEN INFUSION IS SLOW.

INTRAVENOUS CANNULATIONS FOR BLOOD TRANSFUSION CAN BE DONE FROM – • CEPHALIC VEIN • BASILIC VEIN • FOREARM VEINS • GREAT SAPHENOUS VEINS .

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. MONITOR THE PATIENT: • BEFORE STARTING THE TRANSFUSION • 15 MINUTES AFTER STARTING THE TRANSFUSION • AT LEAST EVERY HOUR DURING TRANSFUSION • ON COMPLETION OF THE TRANSFUSION • 4 HOURS AFTER COMPLETING THE TRANSFUSION 2. RECORD: • PATIENT’S GENERAL APPEARANCE • BLOOD PRESSURE. PULSE. FOR EACH UNIT OF BLOOD TRANSFUSED. AT EACH OF THESE STAGES. RESPIRATORY RATE • FLUID BALANCE – ORAL AND IV FLUID INTAKE & URINARY OUTPUT.MONITORING THE TRANSFUSED PATIENT 1.

SEVERE REACTIONS MOST COMMONLY PRESENT IN THE FIRST 15-30 MINUTES OF A TRANSFUSION THEREFORE THEY SHOULD BE CLOSELY MONITORED DURING THIS TIME. IF THE PATIENT APPEARS TO BE EXPERIENCING AN ADVERSE REACTION THE TRANSFUSION MUST BE IMMEDIATELY STOPPED AND URGENT MEDICAL ASSISTANCE SHOULD BE SEEKED FOR. • BLOOD PACK NUMBERS. • ANY ADVERSE EFFECTS. • TIME WHEN THE TRANSFUSION IN COMPLETED. • VOLUME AND TYPE OF ALL PRODUCTS TRANSFUSED. .3. RECORD: • TIME WHEN THE TRANSFUSION IS STARTED.

– . • essential paediatrics – o. • davidson’s principle & practice of medicine – 21st edition – 2010. geneva .p.uk/bloodtransfusionsafety31781/o3.co.REFERENCES: • the who handbook on the clinical use of blood – who blood transfusion safety .bmj. • online text from the british medical journal www. ghai – 6th edition. 2007. • bailey & love’s short practice of surgery – 25th edition – 2008.