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1. BLOOD GROUPING AND
TRANSFUSION PROCEDURE
CHANDINI RAVIKUMAR

2. INTRODUCTION
Blood transfusion- injection of a volume of blood obtained from a healthy person (the donor)
into the circulation of a patient (the recipient) whose blood is deficient in quantity or quality.
Donated blood is subjected to processing after collection, and separated into blood component
by centrifugation.
Standard practices include the major aspects of blood transfusion, such as:
• Careful selection of donors
• Screening and storage of donations for clinical use
• Compatibility testing

3. HISTORY OF BLOOD TRANSFUSION
1492 Pope Innocent suffers a stroke and receives a blood transfusion from three 10-
year old boys. All three boys dies as did the Pope later that year.
1665 Richard Lower in Oxford conducts the first successful canine transfusions
1667 Jean-Baptiste Denis reports successful sheep–human transfusions
1678 Animal human-transfusions are banned in France because of the poor
results.
1818 James Blundell performs the first successful documented human
transfusion in a woman suffering post-partum hemorrhage. She received
blood from her husband and survived.
1901 Karl Landsteiner discovers the ABO system.
1914 The Belgian physician Albert Hustin performed the first non-direct
transfusion, using sodium citrate as an anticoagulant.
1926 The British Red Cross instituted the first blood transfusion service in the
world.
1939 The Rhesus system was identified and recognized as the major cause of
transfusion reactions.

4. PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE
Patients with acute blood loss should receive effective resuscitation immediately.
Clinicians should be aware of the risks of transfusion infections in blood products prescribed
for patients.
Transfusion should be prescribed only when the benefits to the patient are likely to outweigh
the risks.
Clinicians should clearly record the reason for ordering a transfusion (clinical diagnosis).
Trained staff should monitor a patient undergoing transfusion, and must note the signs of an
adverse effect.

5. SCREENING OF BLOOD TRANSFUSIONS
 Objective of screening- detect markers of infection, and prevent release of infected blood and blood components.
 The assay selected for screening should be highly sensitive and specific.
 Donations confirmed positive should be discarded using methods in accordance with standard safety precautions.
Steps in blood screening
 Physical Screening
• Blood donor selection
• Self‐exclusion, deferral
 Laboratory testing: Detection of infection markers; either antibody or antigen

6.  Blood donor recruitment
 Donors are selected according to the following important eligibility criteria:
• General appearance: Donor to be in good physical and mental health
• Age: Between 18 and 60 years of age
• Hemoglobin: Hb shall be not less than 12.5 g/dl for males and 11.5 g/dl for females
• Weight: Minimum 45 kg.
• Blood pressure: Systolic and Diastolic pressures should be normal (systolic: 100‐140 mm Hg and diastolic: 60‐90 mm Hg)
• Temperature: To not exceed 37.5 deg C/ 99.5 deg F.
• Pulse: Pulse shall be between 60 and 100 beats per minute.
• Donation interval: The interval between blood donations shall be 3 to 4 months.
 Blood collection
 The donor should not be fasting before donation.
 If the last meal was taken more than four hours previously, the donor should be given something to eat and drink before donation.

7.  BLOOD AND BLOOD PRODUCTS
1. Whole blood
2. Packed cell
3. Platelet
4. Fresh frozen plasma
5. Cryoprecipitate
6. Protein solution
7. Factor concentrate

8. Whole blood
 450 ml blood in 63 ml anticoagulant‐preservative solution
 Storage: Between +2°C and +6°C in an approved blood bank refrigerator
 Indications:
• Red cell replacement in acute blood loss with hypovolemia
• Exchange transfusion
 Administration:
• Must be ABO and Rh(D) compatible with the recipient
• Never add medication to a unit of blood
• Complete transfusion within 4 hours of commencement

9.  BLOOD SUBSTITUTES: Colloidal solutions used for re-establishment of a normal blood volume in emergency situations, e.g. polytrauma
with severe hemorrhage, massive GI bleed, shock.
1) Albumin
• Used in severe burns (acute severe hypoalbuminemia)
• Used in nephrotic syndrome
• Should not be used in chronic renal disease, chronic liver disease and to treat malnutrition
2) Gelatins
• Good plasma expander
• E.g. haemaccel (1:2,000), gelofusin
3) Dextrans
• Reduces viscosity and red cell sludging.
• May affect renal function and coagulation.
4) Hydroxyethyl starch
• Derived from starch and large doses may interfere with coagulation

10.  BLOOD GROUPS
I. ABO SYSTEM
 Strongly antigenic and associated with naturally
occurring antibodies in the serum.
 Consists of 3 allelic genes- A, B and O
 The system allows for 6 possible genotypes although
there are only 4 phenotypes.
 Blood group O- is universal donor type as it contains
no antigens (A,B and Rh) to provoke a reaction.
 Blood group AB+ is the universal recipients type, and
can receive any ABO blood type as they have no
circulating antibodies.

11. II. RHESUS SYSTEM
 The Rhesus D (Rh D) antigen is strongly antigenic.
 Antibodies to D antigen are not naturally present in serum.
Clinical significance of Rh
 Importance of Rh system is based on immunogenicity of D antigen (it’s ability to stimulate production of anti-D
in D-negative individuals).
 Production of anti-D is important in transfusion therapy and, in women with consequences of hemolytic disease
of the newborn (HDN).
 Exposure of D-negative individuals to D-positive red cells by transfusion or pregnancy is likely to evoke an
immune response, and elicits the production of anti-D in these patients.

12.  D antigen and DU
 D antigen is the most clinically important antigen in Rh blood group system.
 Although D typings are straightforward, some variant or weakened D typings can be encountered.
 These weakened typings present as D-negative (immediate spin reading), and as D-positive (indirect antiglobulin test).
 These variant typings are described as DU phenotype (weak D).
 Reasons for these variant typings include a trans-position effect, genetically transmissible DU, and categories of D.
 Significance of DU testing
 Required on all donor cells that are non-reactive with anti-D in direct or immediate-spin testing.
 Donor red cells are labeled D-negative when, they are D-negative on direct testing and negative following DU testing.
 Donor red cells are labeled D-positive when, they are D-negative on direct testing but positive following DU testing. This is
because these cells can elicit an immune response by anti-D production, if transfused to a D-negative recipient.

13.  CLINICAL TRANSFUSION PROCEDURE
 Indications of blood transfusion
 Hemorrhage (sudden loss of 25% or more of the blood volume)
 Patients undergoing exchange transfusion
 Patients who continue to bleed after receiving 4 units of packed red blood cells
 Indications for packed cell transfusion
 Symptomatic chronic anemia without hemorrhage
 Acute sickle cell crisis
 Cardiac failure
 Acute blood loss (30 % or more)
 Perioperative anemia
 Indications for Platelet transfusion
 Patients with thrombocytopenia
 Correction of coagulopathy
 Prophylactic transfusion in:
• Major surgery or invasive procedures
• Ocular surgery or neurosurgery
• Surgery with active bleeding

14.  Indications for Fresh frozen plasma transfusion
 Deficiencies of coagulation factors or inhibitors of
coagulation
 Emergency treatment of warfarin over dosage and Vitamin
K deficiency
 Treatment of thrombotic thrombocytopenic purpura (TTP)
 Treatment of disseminated intravascular coagulation (DIC)
 Indications for cryoprecipitate transfusion
 Hemophilia
 Hypofibrinogenaemia
 von Willebrand's disease
 Disseminated intravascular coagulation
 Hepatic failure
 Congenital fibrinogen deficiency

15.  Indications for transfusion of protein solution
 Human plasma protein fraction- albumin concentrate,
immune and hyper immune globulins, anti-thrombin 3 and
protein concentrate
• Hypoalbuminemia
• Patient undergoing plasmapheresis
• Patient with nephrotic syndrome
• Liver failure
 Indications for transfusion of factor concentrate
 Examples- Factor VIII, Factor IX-prothrombin complex,
protein C, fibrinogen concentrates and Recombinant factor.
 Hemophilia A and von willebrand disease (factor VIII
concentrate)
 Christmas disease, liver disease (Factor IX- prothrombin
complex concentrate)
 Severe sepsis with DIC (protein C concentrate)

16.  TRANSFUSION TRIGGER
 Historically, patients were transfused to achieve a hemoglobin value greater than 10 g/dl.
 This has been associated with increased morbidity and mortality compared to lower target values.
 Hemoglobin level of 6 g/dl is acceptable in patients who are not actively bleeding, and not about to undergo major surgery.
 There is some controversy as to the optimal hemoglobin level in some patient groups, such as those with cardiovascular
disease, sepsis and traumatic brain injury.
Hemoglobin level (g/dl) Indications
<6 Probably will benefit from transfusion
6-8 Transfusion unlikely to be of benefit in the
absence of bleeding or impending surgery
>8 No indication for transfusion in the
absence of other risk factors

17. Administration of Blood Products
o The process starts with the request for blood, followed by the selection of the correct blood product for compatibility testing
and finally the issuing of compatible blood for infusion into the patient.
o When blood is transfused, the following records should be made note:
 Type and volume of each unit transfused.
 Unique donation number of each unit transfused.
 Blood group of each unit transfused.
 Time at which the transfusion of each unit commenced.
 Signature of the individual
 Record the time of completion of the transfusion.
 Identify and respond immediately to any adverse effect, by stopping the transfusion.
 Record the details of any transfusion reaction.

18.  Blood request form
 Before blood transfusion, the clinician should sign a blood request form, designed to provide necessary information.
 All details on the blood request form must be completed accurately and legibly.
 Should always be accompanied by the patient’s blood sample.
 The sample is placed in a sample tube that is correctly labelled and is uniquely identifiable with the patient.
 The sample shall not be submitted in a syringe, as it could lead to errors when transferring for compatibility testing.
 For a routine case, the sample and request form should be submitted to the transfusion department at least 24 hours before
required, to make sure of the availability of blood.
 Blood samples
 The taking of a blood sample from the patient needs supervision.
 A 5 ml blood sample should be collected into a dry test tube, labelled with the patient’s details, and submitted to the blood
center for testing.

19.  Collection and receipt of blood
 Details on the blood request form is matched with the blood compatibility label, the bag unit number and the patient documentation label.
 If everything matches, the unit must be signed with the date and time.
 If there is any discrepancy, the staff member of the blood transfusion department must be informed soon.
 Inspect pack and contents for signs of deterioration or damage.
 Performing the transfusion
 Transfusion should be commenced within 30 minutes of removal from the optimal storage conditions.
 The temperature inside blood bank refrigerator should be maintained between +2°C and +6°C.
 Checking the patient’s identity
 Before starting the transfusion, it is vital to check the final identity of patient with the hospital’s standard operating procedure.
 The final identity check should be done at patient’s bedside before commencing the administration of the blood product.
 It should be undertaken by two people, among whom one should be a registered nurse or doctor.

20.  Suggested rate of transfusion
 Transfusion rate depends on clinical circumstances and varies from 3‐5 ml/kg/hour to increased rates for individuals in
hypovolemic shock.
 Time limits for transfusion
 There is risk of bacterial proliferation or loss of function in blood products once removed from correct storage conditions.
 Transfusion of a unit of blood should be completed within a maximum period of 4 hours after removal from the blood fridge.
 The unit must be discarded if this period is exceeded.

21.  Blood administration set:
 A new, sterile blood administration set, containing an integral 170‐200µ filter must be used.
 The set should be changed at least 12‐hourly during blood transfusion.
 All blood components can be slowly infused through small‐bore cannulas or butterfly needles, e.g. 21 to 25 G.
 For rapid infusion, large‐bore cannulas are needed. E.g. 14 G.

22.  Monitoring the transfusion
 The patient should be monitored during transfusion,
to detect any adverse event as early as possible.
 Patient should notify a nurse or doctor incase of
any discomfort.
 For each unit of blood transfused, the patient is
monitored at the time of:
• Before starting the transfusion
• 15 minutes after starting the transfusion.
• At least every hour during transfusion.
• Carry out a final set of observations 15 minutes
after each unit has been transfused.

23. COMPLICATIONS OF BLOOD TRANSFUSION

24.  IMMUNE COMPLICATIONS
I. Hemolytic reactions
 Major (ABO) incompatibility reactions
• Result of mismatched blood transfusion and due to technical errors like sampling, labelling, dispatching, etc.
• Causes intravascular hemolysis.
 Clinical features
• Haematuria
• Pain in the loins (bilateral)
• Fever with chills and rigors
• Oliguria due to the products of mismatched blood transfusion blocking the renal tubules, resulting in acute renal tubular necrosis.
 Treatment
• Stop the blood. Send it to blood bank and recheck. Repeat coagulation profile.
• IV fluids, monitor urine output, check urine for Hb.

25.  Minor incompatibility reaction
• Occurs due to extravascular hemolysis.
• Usually mild
• Occurs due to antibodies to minor antigens.
• Manifested with malaise, jaundice and fever. Treatment is supportive.
II. Non-hemolytic reactions
 Febrile reactions
• Occurs due to sensitization to WBCs or platelets
• Increased temperature- no hemolysis
 Allergic reactions
• Occur due to allergy to plasma products that manifest as chills, rigors and rashes.
• Subside with anti-histaminics such as chlorpheniramine maleate 10 mg IV.

26.  Transfusion related acute lung injury (TRALI)
• Rare complication resembling ARDS.
• Anti-leukocyte antibodies cause patient’s white cells to aggregate in pulmonary circulation.
• Typically remits in 12-48 hours of therapy
• No specific therapy. Intensive respiratory and general support in an intensive care unit is required.
 Congestive cardiac failure (CCF)
 Occurs if whole blood is transfused rapidly in patients with chronic anemia.
 Treatment
• Slow transfusion
• Injection Furosemide 20 mg IV
• Packed cell transfusion is the choice in these patients

27. o INFECTIOUS COMPLICATIONS
 Serum hepatitis, AIDS, Malaria, Syphilis are dangerous infectious diseases transmitted by blood from one
patient to another.
 Danger increased in cases of multiple transfusions and emergency situations.
 Hence, it is mandatory to screen the blood for these diseases before transfusion.
Disseminated intravascular coagulation (DIC)
 Occurs in massive blood transfusion wherein all factors of coagulation are used up resulting in a bleeding
disorder.
 It produces a severe afibrinogenemia.
 Treated by replacement with fibrinogen (cryoprecipitate) and other clotting factors.

28.  MASSIVE BLOOD TRANSFUSION
 Defined as the replacement of 10 units of blood in any 24 hour period or 5 units of blood in any four‐hour period in an adult.
 Indications: severe trauma, ruptured aortic aneurysm, surgery and obstetric complications.
 The goals to the management of massive transfusion include:
• Maintenance of tissue perfusion
• Oxygenation by restoration of blood volume and Hb
• Cessation of bleeding
 Complications of massive transfusion
 Progressive loss of coagulation factors during storage (Factors V and VIII) unless stored at –30°C or colder.
 Dilution of coagulation factors and platelets will occur following administration of large volumes of replacement fluids.

29. Massive Transfusion Protocol
 Massive transfusion protocol (MTP) should be used in critically bleeding patients anticipated to require massive transfusion.
 Certain parameters should be measured early and frequently (every 30‐60 minutes, or after transfusion of blood component).
 Mortality is high in massive transfusion and its etiology is multifactorial, which includes hypotension, acidosis,
coagulopathy, shock and the underlying condition of the patient.
 The lethal triad of acidosis, hypothermia, and coagulopathy have the highest mortality rate.
Parameters in massive transfusion- Investigation and monitoring

30.  CROSS-MATCHING
 To prevent transfusion reactions, all transfusions are preceded by ABO and rhesus typing of both donor and
recipient blood.
 The recipient’s serum is mixed with the donor’s cells to confirm ABO compatibility (immediate spin testing), and
to test antigen-antibody reaction.
 Full cross-matching of blood may take up to 45 minutes in most laboratories.
 In urgent situations, ‘type specific’ blood is provided which is only ABO/rhesus matched, issued within 10-15
minutes.
 When blood must be given emergently, group O- (universal donor) blood is given.

31.  TRANSFUSION IN PEDIATRICS
 Pediatric anemia is defined as a reduction of Hb concentration or RBC volume below the normal values for healthy children.
 Indications
 Hb ≤4 g/dl
 Hb 4‐6 g/dl with presence of clinical features such as hypoxia, acidosis and impaired consciousness.
 Top‐up transfusion
• Top‐up transfusions are carried out to raise Hb concentration in pre-term babies, due to frequent blood testing.
• PRBC should be used for top‐up transfusions. Red cells in optimal additive solutions, e.g. SAG‐M or CPD blood can be
safely used.
• Transfusion rates of 5 ml/kg are safe. More than 20 ml/kg are not recommended due to the risk of Transfusion-associated
circulatory overload (TACO).

32. OTHER ASPECTS OF BLOOD TRANSFUSION
o AUTOLOGOUS BLOOD TRANSFUSION (ABT)
 It is the collection and subsequent re-infusion of patient’s own blood.
 A patient who receives his or her own blood, receives the safest possible blood because no foreign antigens are
introduced.
 ABT has been gradually accepted and the volume of autologous blood storage in hospitals has also gradually
increased.
 ABT can avoid the spread of blood-borne diseases and immunosuppression, and sometimes it is the only blood
supply in cases where the needed type of blood is not available in a short time.
 ABT can avoid the serious harm caused by allogeneic blood transfusion.

33. Advantages
 Saving of blood resources
 High safety and efficiency
 Mild dilution of blood
 Reduction in blood viscosity
 Improved microcirculation
 Prevention of hypoxia caused by anemia
after blood donation
 No adverse reaction occurs
 Prevention of spread of diseases
Types
 Preoperative autologous blood donation (PABD)
 Acute normovolemic hemodilution (ANH)
 Intraoperative blood salvage
 Postoperative blood salvage
A review of the application of autologous blood
transfusion. J Zhou. Brazilian Journal of Medical and
Biological Research, (2016), 49(9).

34.  Indications
 To prevent transfusion-transmitted diseases
 To protect patients with previous histories of severe transfusion reactions
 To prevent alloimmunization in the recipient
 Criteria for Autologous donation
 Hemoglobin- acceptable at 11g/dl
 Age- No upper or lower age limit
 Frequency of donation- No more often than every 3 days
o Patients who need to store multiple units prior to surgery may be guided to participate in a program of phlebotomy alternating with autologous
transfusion known as “leap-frogging”.
o In the process, patient donates 2 or 3 units of blood over the period of 7 days. Then the oldest unit is transfused to the patient and 2 more
units are withdrawn.

35. Warming blood
 There is no evidence that warming blood is beneficial to the patient when transfusion is slow.
 At transfusion rates of greater than 100 ml/minute, cold blood may be a contributing factor in cardiac arrest.
 However, keeping the patient warm is probably more important than warming the blood.
 Warmed blood is most commonly required in large volume rapid transfusions.
 Blood should only be warmed in a blood warmer.
 Blood should never be warmed in a bowl of hot water as this could lead to hemolysis of the red cells which
could be life‐threatening when transfused

36.  Use of medication at time of transfusion
 It is generally not recommended to routinely use pre‐medication like anti‐histamines and steroids before transfusion.
 Masks or delays the signs and symptoms of transfusion reactions and therefore delay the action to stop the transfusion.
 Addition of medicine or other fluids with blood and blood components
 Medicines or other fluids should never be infused within the same line as blood and blood components.
 The exception is normal saline (sodium chloride 0.9%) which may be used in special circumstances
 Uses of fresh blood (stored blood less than 7 days old)
 Renal and liver dysfunction.
 Patient requiring massive blood transfusion.
 Patient with raised plasma potassium due to extensive burns, or intravascular haemolysis.

37. BLOOD TRANSFUSION IN OMFS
 Blood transfusion is indispensable for oxygen transfer to hypoxic tissues and plasma volume expansion during bleeds.
 Perioperative blood transfusion is of great importance for oral and maxillofacial surgery supportive treatment.
 However, allogeneic blood transfusions may have deleterious effects on the short and long-term prognosis of patients
undergoing surgery for head and neck procedures.
 Allogenic blood transfusion is associated with reduced survival rate and increased recurrence rates in patients having free-
flap primary surgery for OOSCC.
 Transfusion volume is a perioperative factor for post-op complications in patients undergoing oral and maxillofacial surgery.
 Therefore, the transfusion risk of patients should be evaluated pre-surgery to minimize perioperative allogeneic blood
transfusions to ensure patient safety.
Developing a predictive risk score for perioperative blood transfusion: a retrospective study in patients with OOSCC
undergoing free flap reconstruction surgery. Jun-Qi Su1, Shang Xie, Zhi-Gang Cai, Xiao-Ying Wang. Ann Transl Med
2021;9(10):854.

38.  Excessive blood loss occurs in 1%–11% of facial bone fractures.
 While blood loss during OGS has been studied extensively, little attention has been given to other maxillofacial procedures.
 Evaluating amount of blood loss during facial bone fractures can help predict need for blood products in specific procedures.
 Blood loss in patients with maxillofacial surgery was 77.6 ml, and none of them needed blood transfusion during surgery.
 The findings of the study showed that there is no need for blood transfusion in maxillofacial trauma patients who had no systemic disease,
neurological injuries, loss of consciousness, or concomitant injuries in other parts of their bodies.
 Blood loss in facial bone fracture surgeries is lower than other maxillofacial surgeries, such as orthognathic surgeries.
Annals of Maxillofacial Surgery, 2020

39.  REFERENCES
1. Textbook of Blood Banking and Transfusion Medicine, Sally V. Rudmann, 2nd edition.
2. Bailey and love’s Short Practice of Surgery, 26th edition.
3. Manipal manual of surgery with clinical methods for dental students, Rajgopal Shenoy. K, 2nd
edition.
4. Clinical Transfusion Practice, World Health Organization.

40. THANK
YOU