1. Blood transfusion involves infusing blood or blood components into a patient's circulation to replace lost blood or treat anemia. It requires matching the donor and recipient's blood type and Rh factor to avoid dangerous transfusion reactions. 2. Complications can include infectious disease transmission, allergic reactions, lung injury, circulatory overload, and hemolytic reactions if the blood types are incompatible. Careful screening of donors and products, as well as monitoring during transfusion, aims to prevent complications. 3. Different blood components - including whole blood, red blood cells, platelets, and plasma - are used to treat various conditions like blood loss, anemia, low platelet counts, or coagulation disorders. The appropriate

2. Blood Transfusion
Presentation by
Dr.Faisal Zia
Resident Surgeon
Lady reading Hospital Peshawar

3. History………
 1901
 Karl Landsteiner
discovers the ABO
system.

4. History………
 1926……..The British Red Cross
instituted the first blood transfusion service
in the world.
 1939……….The Rhesus system was
identified and recognised as major cause
of transfusion reactions.

5. Introduction
 An adult human has about 4-6 litres of
blood circulating in the body.
 Among other things blood transport oxygen
to various tissues of the body.
 Blood consists of several types of cells
floating around in a fluid called plasma.

6. Intro……

8. Intro……………
 The red blood cells contain
hemoglobin,a protein that binds
oxygen.
 Red blood cells transport oxygen to,and
remove carbon dioxide from the body
tissues.
 The white blood
cells(neutophils,eosinophils,basophils,
monocytes,lymphocytes) fight infection.
 Platelets help in blood clotting.

9. Intro……………
 The plasma contains salts and various
kinds of plasma
proteins(albumin,globulin,clotting
factors etc).
 Plasma makes 55 percent of the blood
volume approximately.

10. Intro……….
 DEFINATION:
A blood
transfusion is the infusion
of whole blood or blood
components such as
plasma,red blood cells or
platelets into the venous
circulation of the patient.

11. Intro………..
 Purposes:
 To replace blood lost during surgery or
a serious injury.
 To restore oxygen carrying capicity of
the blood.
 To provide plasma factors to prevent or
treat bleeding.
 If patients body is not capable of
making blood properly because of an
illness.

12. Indications
Indications are as follows:
 Acute blood loss, to replace circulating
volume and maintain oxygen delivery.
 Perioperative anemia to ensure
adequate oxygen delivery during the
perioperative phase.
 Symptomatic chronic anemia,without
hemorrhage or impending surgery.

13.  Human blood is commonly classified into four
main groups .
 (A, B, AB, and O).
 The surface of an individual’s red blood cells
contains a number of proteins known as antigens
that are unique for each person. Many blood
antigens have been identified, but the antigens A,
B, and D(Rh) are the most important in
determining blood group or type.
Blood groups

14. Blood groups
 The A antigen or agglutinogens is present on
the RBCs of people with blood group A , the
B antigen is present in people with blood
group B, and both A and B antigens are
found on the RBC surface in people with
group AB blood .Neither antigen is present in
people with group O blood .

15. Blood groups
 People with blood group A have B antibodies
(agglutinins ), A antibodies are present in
people with blood group B , and people with
blood group O have antibodies to both A and B
antigens .People with group AB blood do not
have antibodies to either A or B antigens .

16. Blood groups
 If a person with type O blood is transfused with
blood from a person with either group A or
group B blood, there would be destruction of
the recipient’s red blood cells because his or her
anti-A or anti-B agglutinins would react with
the A or B antigens in the donor’s red blood
cells.

17. Blood groups
 This example shows why individuals with type AB
blood are often called Universal recipients
(because people in this blood group have no
agglutinins for either A or B antigens) and group
O people are often called Universal donors
(because they have neither A nor B antigens).

18. Blood groups

19. Blood groups

20. Blood groups

21. Blood groups

22. A,B,AB & O BLOOD
GROUP

23.  The Rh factor is an inherited antigen in human blood.
 Blood that contains the Rh factor is known as Rh
positive, when it is not present the blood is said to be Rh –
negative.
 Rh blood does not naturally contain Rh antibodies.
 If Rh-positive blood is injected into an Rh-negative
person, the recipient develops Rh antibodies.
 Subsequent transfusion with Rh-positive blood may
cause serious reactions with clumping and hemolysis of
red blood cells.
Rhesus Rh Factor

24.  Before any blood can be given to a patient, it must
be determined that the blood of the donor is
compatible with the patient.

 The laboratory examination to determine a
person’s blood group and Rh factor is called
Blood Typing.

25. Cross matching
 The process of determining compatibility
between blood specimens is crossmatching.
 RBCs from the donor blood are mixed with
serum from the recipient, a reagent (Coombs’
serum) is added, and the mixture is examined
for visible agglutination.
 If no antibodies to the donated RBCS are
present in the recipient’s serum, agglutination
does not occur and the risk of transfusion
reaction is small.

26. Transfusion trigger
 Historically patients were transfused to
achieve hemoglobin >10g/dl.This has
been shown to not only be unnecessary
but also be associated with an
increased morbidity and mortality
compared to low target values.
 A hemoglobin level of 6g/dl is
acceptable in patients who are not
actively bleeding,not about to undergo
major surgery and not symptomatic.

27. Transfusion trigger
There is some controversy as to optimal
hemoglobin level in some patient
groups,such as those with
cardiovascular disaease,sepsis and
traumatic brain injury.
 Although conceptually a higher
hemoglobin improves oxygen
delivery,there is little clinical evidence at
this stage to support higher levels in
these groups.

28. Transfusion trigger
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.

29. Administering blood
 Blood transfusions take place in either a
Doctors office or a hospital.
 They can be done at the patients home,but
this is less common.

30. Administering blood
 A needle is used to insert an intravenous(IV)
line into a blood vessel,through this line blood is
transfuse.
 The procedure usually takes one to four hours.
 The time depends on how much blood is
needed,which blood product is given,and
whether the patients body can safely receive
blood quickly or not.

31. Administering blood
 During blood transfusion,a doctor or nurse
carefully watches the patient,especially for
the first 15 minutes,this is when bad
reactions are most likely to occur.

32. Administering blood
 After blood transfusion vital signs are
checked(such as temprature,blood
pressure,respiration rate and heart rate).
 Follow up blood tests may be necessary to
show how the body is reacting to the
transfusion.

33. BLOOD PRODUCTS
PLATELETS FRESH FROZEN
PLASMA

34. Whole blood:
• Indicated for Rx of acute Hemorrhage.
• Transfusion should complete within 4 hrs.
• Warmer is used if large volume in a short time.
• Coagulation factor rich.
• If fresh more metabolically active then store
blood.
• Unwanted features in Store blood.
1 .Citrate anticoagulant.
2 .Acidic PH.
3 .High K.
4 .Ammonia.
5 .Dec 2,3-DPG level.

35. Red cell preparation:
• Packed RBC’s are spun down and
concentrated.
• Obtained from single donor.
• Ideal for anemia Rx.
• 1 Unit = 330 ml and inc HCT by 3% & HB
1g.

36. Frozen Red cells:
 Storage at -80 to – 196 C through
cytoprotective agents like Glycerol.
 Result in removal of Leukocytes , Platlets
and any viral particles.
 Reduce disease transmission incidence.

37. Platelets:
• Available as concentrates from single
or multiple donors.
• Indicated for thrombocytopenia, to
cover surgery if count is below
40,000, in pt with platelet dysfunction.
• HLA expression and may lead to
Alloimmunization in pt requiring
repeated platelet transfusion.
• Patient with platelets
alloimmunization can only receive
HLA matched platelet conc.

38. Platelets:
• 1 unit= 50 ml and increase platelet count
by abt 10,000.
• Stored at 20 to 24 C.
• Shelf life 5 days.

39. Fresh-frozen plasma:
• Coagulation factors rich.
• Stored at -40 to -50 C (shelf life of 2 yrs).
• 1 unit= 200 ml.
• Dose = 15 to 25 ml/kg.
Indicated in:
○ Coagolupathic Hemorrhage.
○ Reverse oral anticoagulation ( warfarin/
coumarin).
○ Provide haemostatic support & to cover
liver disease procedures.
○ DIC.
○ Massive Transfusion.
○ Burns.

40. Cryoprecipitate:
• Supernatant ppt of FFP.
• Concentrate of factor VIII, von Willebrand’s
factor and fibrinogen.
• Stored at -30 C (shelf life 2 yrs).

41. Indications of Cryoprecipitate:
• Factor 8 deficiency.
• Fibrinogen deficiency.
•
• Von Willebrand’s disease.

42. Prothrombin complex conc:
 Highly purified conc prep from pooled
plasma contains Factor 2, 7, 9, 10.
 Indicated for emergency reversal of
anticoagulant therapy ( warfarin), in
uncontrolled hemorrhage.

43. FACTOR 8 CONCENTRATE:
 Haemophilia
FACTOR 9 CONCENTRATE:
 Christmas disease

44. Autologous blood
Transfusion
 Autologous Predonation
 It is possible for patients undergoing elective
surgery to predonate their own blood upto 3
weeks before surgery for retransfusion
during the operations.
 Intraoperative Autotransfusion
 During operations blood can be collected in
a cell saver which washes and collects red
blood cells which can then be returned to the
patient.

45. Massive Transfusion
Definitions:
 Transfusion of blood products that are
greater in volume than a patients
normal blood volume in less than 24
hrs.
 Transfusion of >10 units RCC in 24
hours.
 Replacement of >50% of the total blood
volume within 3 hours.

46. Massive Transfusion
Settings:
• Trauma
• Obstetric
• Surgical
• Medical

47. Transfusion
complications
They can be categorised into:
 Complications from a single
transfusion.
 Complications from massive
transfusion.

48. Transfusion
Complications
Complications from a single transfusion:
1. Infectious complications.
2. Non infectious complications:
 Acute(<24 hrs):
 Immunological
 Non-immonological
 Delayed(>24 hrs):
 Immunological & non-
immunological

49. Infectious complications
• Bacterial (brucellosis, syphilis)
• Helminthic (filariasis)
• Protozoal (malaria, toxoplasmosis)
• Rickettsial
• Viral (HIV, CMV, Epstein-Barr virus,
hepatitis A, B and C and yellow fever)

50. Non infectious
complication
Acute(<24 hrs):
 Immunological:
 Urticarial/Allergic.
 Anaphylactic.
 Non-hemolytic febrile transfusion
reactions.
 Hemolytic transfusion reactions.
 Trasfusion related acute lung
injury(TRALI).

51. Non infectio…………
Acute(<24 hrs):
 Non immunological:
 Circulatory overload.
 Hypocalcemia.
 Hypothermia.
 Air embolism.
 Septic shock(bacteremia)

52. Acute immunological
reactions
Urticarial/Allergic reactions:
 The most common type of transfusion
reactions and occur when the patient
reacts to donated plasma proteins in the
blood.
 Symptoms include itching or hives and can
be treated with
antihistamines(diphenhydramine 25-50mg
orally or IV).
 Prophylactic administration of benadryl
and prednisolone prior to transfusion
should be considered in patients with
previous history of allergic reactions.

53. Acute immuno………….
Anaphylactic reactions:
• Rare, fatal,severe reaction caused by
antibodies to IgA in patients who have
extremely low levels of this
immunoglobulin in plasma.
• Causes hypotension,cutaneous
flushing and even bronchospasm or
laryngospasm,which should prompt
discontinuation of infusion.

54. Acute immuno……….
Treatment:
• Cessation of transfusion.
• IV crystalloids.
• Maintain airway and O2.
• Adrenaline 0.5 – 1 mg i.m.
• IV anti histamine/IV steroids.
• salbutamol nebulization.

55. Acute immuno……..
Non-haemolytic febrile transfusion reactions:
• Result of alloimmunization to leucocyte
and platelet antigens.
• Symptoms: general
malaise,chills,nausea,or headache
accompanied by fever usually during or
within 24 hrs of transfusion.
• Managed by cessation or slowing of the
transfusion and administration of an
antipyretic.
• If above measures fail, leukocyte-depleted
cell components are given.

56. Acute immuno…………
Acute hemolytic transfusion reaction:
• Result of ABO or Rh incompatibility
• Serious complication mostly due to
clerical error.
• Mortality is high when more than 200
ml has transfused Symptoms include
nausea,chills,anxiety,flushing and
chest or back pain.
• Anesthetized or comatosed patients
may show signs of excessive incisional
bleeding or oozing from mucous
membranes.
• The reaction may progress to shock or
renal failure with hemoglobinuria.

57. Acute immuno………
Management :
○ Immediate recognition and cessation of transfusion.
○ Replacement of the giving set.
○ Adequate hydration with IV crystalloids.
○ Urine output should be maintained at greater than 100
ml/hr using volume resuscitation and possibly
diuretics.
○ Force diuresis with furosemide 150mg, mannitol 100ml
20%, haemodialysis.
○ Alkanization of urine to a pH greater than 7.5 by
adding sodium bicarbonate to IV fluids helps to
prevent precipitation of hemoglobin in the renal
tubules.

58. Acute immuno………..
Further investigations:
• Re-cross matching and
serological testing.
• Blood unit for culture.
• Blood sample for clinical
chemistry.
• Coagulation screen.

59. Acute immuno………..
Transfusion-related acute lung injury(TRALI):
 TRALI is a serious reaction that typically
occurs within 1 to 2 hours of transfusion but
can occur anytime upto 6 hrs later.
 TRALI is an infrequent complication caused
by anti-HLA and/or anti-granulocyte
antibodies in donor plasma that agglutinate
and degranulate recipient granulocytes
within the lung.
 Patient complains of shortness of breath
and may have a fever.

60. Acute immuno………..
 Chest x-ray has a characteristic pattern of
noncardiogenic pulmonary edema.
 After ABO incompatibility, this is the 2nd most
common cause of transfusion-related death.
 Incidence is 1:5,000–10,000, but many cases
are mild.
 Mild to moderate transfusion-related acute
lung injury probably is commonly missed.

61. Acut immuno…………
Management:
 Support may vary from supplemental
oxygen, to intubation and ventilation.

62. Acute non-immnological
Circulatory overload:
 The high osmotic load of blood products
draws volume into the intravascular space
over the course of hours, which can cause
volume overload in susceptible patients (eg,
those with cardiac or renal insufficiency).
 RBCs should be infused slowly.

63. Acute non-immuno………
 The patient should be observed and, if
signs of heart failure (eg, dyspnea,
rales) occur, the transfusion should be
stopped and treatment for heart failure
begun.
 Judicious use of diuretic therapy can
reduce the risk of this complication.

64. Acute non-immuno………
Air embolism:
 Air infusion via line
 Rare
 Cough, dyspnea, chest pain, shock
 If suspected…
• Pt. placed on left side with head down.
• Displace air bubble from pulmonary
valve.

65. Non infectious
complications
Delayed(>24)hrs:
 Immunological:
 Delayed hemolytic transfusion reactions.
 Graft versus host disease(GVHD).
 Immune-modulation.
 Non immunological:
 Transfusion iron overload(haemosiderosis).

66. Delayed immunological
Delayed hemolytic transfusion reaction:
 It results from an anamnestic antibody
response to antigens other than the ABO
antigens to which the recipient has been
previously exposed.
 Transfused blood cells may take days or
weeks to hemolyze after transfusion.
 Typically there are few signs and
symptoms other than a falling RBCs
count and elevated bilirubin.

67. Delayed immuno……….
Management:
 Specific treatment is rarely necessary.
 Severe cases shoud be treated like acute
hemolytic reactions,with volume support
and maintanace of urine output.

68. Delayed immuno…………
Graft-versus-host disease:
• Rare, but fatal complication,having
associated mortality of greater than 80
percent.
• Occurs mainly in immunocompromised
patients or HLA-identical family members.
• Caused by immuno competent T-
lymphocytes, immunologicaly competent
transfused cells attack host environment.
• Starts 3-30 days after the transfusion.

69. Delayed immuno………….
• Develop high fever, diffuse erythematous
skin rash, desquamation, GI symptoms,
severe hepatic dysfunction and
pancytopenia.
• Prevented by administering gamma-
irradiated cellular components.

70. Delayed immuno………..
Immuno-modulation:
 Increases risk of recurrent cancer and
bacterial infections.
 WBCs release cytokines during storage
which interfere with immune function.
 Uncertain clinical significance.
Treatment:
 Leukoreduction of blood products.

71. Delayed non-
immunological
Transfusion iron overload(haemosiderosis):
 Each unit of packed red cells 200-250 mg of
Fe.
 Repeated transfusions over a long period of
time(e.g in childeren with thalesemia and in
patients with chronic refractory anemia).
 > 50-100 units of PRBC
 Storage in RE sites  saturation  other sites
 Heart, liver, endocrine glands (pancreas)

72. Delayed non-
immunological
Treatment:
 Removal of Fe
 Desferoxamine – Fe-chelating agent

73. Transfusion
complications
Complications from Massive
transfusion:
 Dilutional thrombocytopenia
 Coagulopathy
 Hypocalcemia
 Hypothermia
 Hyperkalemia
 Hypokalemia
 Acidosis
 Citrate toxicity

74. Complications of massive
transfusion
Dilutional thrombocytopenia:
 When a patient receives stored blood in such
large volume, the patient's own blood may be, in
effect, “washed out.”
 In circumstances uncomplicated by prolonged
hypotension or DIC, dilutional thrombocytopenia
is the most likely complication.
 Platelets in stored whole blood are not
functional. Clotting factors (except factor VIII)
usually remain sufficient.
 Microvascular bleeding (abnormal oozing and
continued bleeding from raw and cut surfaces)
may result.

75. Complications of mas…....
Treatment:
 Five to 8 (1 unit/10 kg) platelet
concentrates are usually enough to
correct such bleeding in an adult.

76. Complications of
mas………..
Coagulopathy:
 Coagulopathy might arise as a result of
platelet and coagulation factors
depletion.
 Coagulopathy following or during
massive transfusion should be
anticipated and managed aggressively.

77. Complications of
mas……….
Management:
 Standard guidelines are as follows:
 FFP if PT or APTT > 1.5 times normal.
 Cryoprecipitate if fibrinogen < 0.8g/l.
 Platelets if platelet count < 50×109/ml.

78. Complications of
mas…….
Hypocalcemia:
 When large volumes of FFP, whole blood,
plts. transfused rapidly  plasma citrate
levels may rise  binds to Ca+2.
 Symptoms include Periorbital/peripheral
tingling,paresthesias, shivering, light
headedness, tetanic symptoms,
hyperventilation, depressed cardiac
function.
 Treatment: IV 10% calcium gluconate.

79. Complications of
mas……..
Hypothermia:
 Rapid infusion of large volumes of chilled
blood products leads to hypothermia.
 More likely to occur via central catheters.
 It can lead to cardiac dysrhythmias and
coagulopathy.
 It can be prevented by using blood warmers.

80. Effect of Hypothermia on
coagulation factor activity
0
20
40
60
80
100
25° 27° 29° 31° 33° 35° 37°
Temperature
FactorActivity
II
V
VII
VIII
IX
X
XI
XII

81. Complications of
mas……..
 Citrate toxicity can develop after massive
transfusion in patients with hepatic
dysfunction.
 Elecrolyte abnormalities,including Acidosis
and Hyperkalemia,occur rarely after
massive transfusions,especially in patients
with pre-existing hyperkalemia.

82. Blood substitutes
 They are an attractive alternative to the
costly process of
donating,checking,storing and
administering blood –and due to the
complications associated with transfusion.
 Several oxygen-carrying blood substitutes
are under investigation in animal or early
clinical trials.
 They are either Biomimetic or Abiotic.

83. Blood sub………..
 Biomimetic substitutes mimic the
standard oxygen carrying capicity of
blood and are haemoglobin based.
 Various engineered molecules are under
clinical trials,based on human,bovine or
recombinant technlogies.
 Abiotic substitutes are synthetic oxygen
carriers and are currently primarily
perfluorocarbon based.

84.  A 29 year old woman on oral conraceptives
presents with abdominal pain. A CT scan of
the abdomen demonstrates a large
hematoma of the right liver with the
suggestion of a underlying liver lesion. Her
Hb = 6 and she is transfused 2 units of
packed RBC 2 units of FFPs. 2 hr after
starting the transfusion, she Develops
respiratory distress and requires and
requires intubation. She is not volume
overloaded clinically, but her x-ray shows
bilateral Pulmonary inFiltrates. Which of
the following is the the management
strategy of Choice??

85.  A. continue the transfusion and
administer an antihistamine
 B. Stop the transfusion and administer a
diuretic
 C. Stop the transfusion and continue
supportive Respiratory care
 C. Stop the transfusion and send a
Coombs test

86.  Answer = C
 The patient has TRALI which manifests
as respiratoy disress, hypoxemia and
bilateral infiltrates not due to volume
overload.
 The treatment is respiratory support
including mechanical ventilation, as
needed.

87. Take Home Message
 Next time, when u transfuse Blood, u should take care of
all the following points.
 Check the blood bag identification number, ABO Blood group
and Rh compatibility.
 Check the expiry date on the blood bag.
 Observe for abnormal color, RBC clumping, & extraneous
material.
 Return outdated or abnormal blood to the blood bank.
 Before starting transfusion, make sure u r aware and Ready for
any Reaction. i-e u should have Steroid (Dexamethasone) and
Antihistamine (AVil) on ur Emergency Tray.
 Ask about previous transfusion and Reaction if Occured
 Write down the Transfusion Notes and counsil the patient about
reaction
 Observe the patient Vitally and Generally ( Skin Rash et) for any
reaction specially in first 15 min. coz most reactions occur in 1st
15 min.
 After transfusion, DO HB to Check for attainment of Desired HB.
 Also DO S.E for any Abnormality if previously deranged SE.