This document provides guidelines for blood and blood component transfusion. It discusses the various blood components, quality control parameters, rationale for transfusion in different clinical settings, transfusion guidelines including blood group shifting, use of leukoreduced and irradiated blood products, and the impact of oral antiplatelet therapy. It aims to update best practices for blood transfusion safety.

1. BLOOD & BLOOD
COMPONENTS TRANSFUSION GUIDELINES
- AN UPDATE
Dr Rajesh V Bendre
Chief Pathologist,
Laboratory & Blood Bank
1

2. Product: Blood Safety
Entire process: Blood Transfusion Safety
Recruit donor
Screen donor
Collect unit
Prepare components
Infectious diseases
testing
Pre-TX testing
Medical reason to TX
Issue unit
Administer-Bedside/OT
Monitor & evaluate
Blood Transfusion Therapy includes set of processes with
Multidisciplinary Involvement.
BLOOD IS CONSIDERED AS A DRUG WITH – A VARIABLE SAFETY PROFILE - UNDER FDA REGULATION
Blood Bank Personnel Nurses, Surgeons, Anesthetists,
Hematologists, Physicians

3. Blood Components
Centrifugation-Buffy coat Method-
Universal Leukoreduction (In vitro)
 Packed red cells
 Platelets-RDP
 Fresh Frozen Plasma
 Cryoprecipitate
Apheresis services-
(In vivo)
• Platelets- SDP
• Granulocyte harvesting
• Stem cell harvesting

4. Sr.
No
Blood & Blood
Components
Quality Control Parameters Frequency Of Control
1. Whole Blood a)Volume- 350/450ml, b)HCT - >30%
c) Sterility –By Culture, d) Negative Serology
1% of all units
2. Packed Cell
Concentrate-
Leukoreduced
a)Volume- 245-325 ml b)HCT – 55-65%
c) Sterility –By Culture d) Negative Serology
e)Residual Leucocyte count<5x106
1% of all units
3. Platelet Concentrate-
RDP
a) Volume -50-90ml b) Plt.count ->5.5x1010
c) PH ->6.0 d) RBC contamination-Traces to 0.5ml
e) Residual leucocyte count <8.3x105 f) Sterility – By Culture
1% of all units
4. Fresh Frozen Plasma-
FFP
a) Volume - >180ml b) PT & APTT
c) Factor VIII – 0.7units/ml d) Fibrinogen >200mg
1% of all units
5. Cryoprecipitate a) Volume – 10-20ml b) Factor VIII – >80 units/ml
c) Fibrinogen >150mg
1% of all units
6. Single Donor Platelet-
SDP
a)Volume >200 ml b) Plt.count ->3.0x1011
c) PH ->6.0 d) RBC contamination-Traces to 0.5ml
e) Sterility –By Culture f) Negative- Serology g)Residual
Leucocyte count<5x106
All units
7. Granulocyte Conc.by
apheresis
a) Granulocyte Count ->1x1010 b) Plt.count -2-10x1011
c) Red Cell -5-50 ml d) Plasma -200-400ml e) Negative- Serology
All units
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BLOOD BANK- QUALITY CONTROL
(NBTC, AABB, NABH)

5. BLOOD BANK- QUALITY INDICATORS (NABH, NBTC)
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a. Percentage of Transfusion Reactions. (Goal-Nil, often <0.2%)
b. Percentage of Wastage of blood and blood components. (Both on shelf & post-Issue <1%)
c. Percentage of Blood component usage. (Minimal usage of whole blood, Product usage with
appropriate rationale)
d. Turn around time for issue of blood and blood components. (Defined appropriately by
Institution- Emergency <5mins, Routine- <15mins)
e. Percentage of Reactive TTI & Atypical Antibody (HBV- <2%, HIV-<0.2%, HCV- <2%,
VDRL- <0.1%, Atypical antibody - <1%, Malaria-<0.03%)
f. Percentage of Adverse Donor Reaction (<2%)

6. Tests prior to Transfusion
•ABO & Rh typing
• RBC Irregular Antibody
screen
For WB, PC- Compatibility Test (x-match)
Donor red cells + patients serum
Saline and LISS Coombs
Hospital
BB
Hospital BB
Donor Patient
•ABO & Rh typing
•RBC Irregular
Antibody screen
Donor

7. ABO/Rh(D) Typing
Group B RhD
positive
Crossmatching (Major)
ABO/Rh(D)
Group
Crossmatch
Patient B
Positive
Recipient Serum
Donor Red Cells
Compatible

8.  Rationale- What does your patient
need? - Why? How much? When?
Alternatives?
 Obtain Transfusion Consent
 Written Order for transfusion from
clinician
 Follow steps in HIS for Arrange voucher
(ensuring adequate lead time for
coordination required to comply with
blood requirements, especially Rare blood
groups)
 Obtain Patient Sample and send to Blood
Bank
 Follow steps in HIS for Issue voucher
before time of transfusion
8ORDERING A BLOOD TRANSFUSION:

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Safe Transfusion Practices

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Guidelines for the use of blood transfusion have been published by many scientific
societies. Some of the recent ones are from –
• The American Society of Anesthesiologists (2006, 2014),
• The Society of Critical Care Medicine (2009),
• The American Association of Blood Banks (AABB) (2019),
• NBTC & NABH Blood Bank Guidelines (2015)
• The American College of Physicians (2013) and
• The British Committee for Standards in Haematology (2013).
Most recommend the use of Restrictive & Goal based transfusion strategy.
However, high-quality evidence with larger data is available only for few clinical
settings.
Transfusion Guidelines

11. PATIENT BLOOD MANAGEMENT (PBM)-
in surgery
11
Three Pillars
Maximize &
conserve
blood
production
after surgery
Optimize
patient
before
surgery
Minimize
blood loss
during
surgery
Peri-Operative

12. PBM surgical Strategies
OPTIMIZE PATIENT
BEFORE SURGERY.
 ASSESS PATIENT
FITNESS FOR SURGERY.
 CORRECT BLEEDING
DISORDERS.
 ASSESS MEDICATIONS
AND HERBS THAT
INCREASE BLEEDING.
 CORRECT ANEMIA.
 DEVELOP
INDIVIDUALIZED PLAN
OF CARE.
• Adapted from Goodnough LT, et al. Transfusion. 2003;43:668-676.
• Hofmann A, Friedman D, Farmer S. Western Australia Patient Blood Management Project 2008-2012
Minimize blood loss
during surgery.
 Precise surgical
technique.
 Surgical devices that
control bleeding.
 Drugs that control
bleeding.
 Minimally invasive
technology.
 Anesthesia & fluid
management.
 Blood salvage.
Maximize &
conserve blood
production after
surgery.
 Monitor and correct
bleeding.
 Tolerance of
permissive anemia.
 Increase patient
blood production.
 Minimize blood
sampling.

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Rationale & Trigger for Transfusion- Maximum Surgical Blood Order Schedule

15. 15
Post-operative patients
In haemodynamically stable post-operative surgical patients, the trigger for transfusion is Hb ≤ 8 g/dl or
presence of symptoms of inadequate oxygen delivery (chest pain of cardiac origin, orthostatic
hypotension or tachycardia unresponsive to fluid resuscitation, or congestive heart failure).
Patients in the intensive care unit
In critically ill normovolaemic patients transfusion is considered at a Hb level of ≤7 g/dl with a target of 7-
9 g/dl,
unless specific co-morbidities or acute illness-related factors modify clinical decision-making-
During early resuscitative phase of severe sepsis if there is evidence of inadequate oxygen delivery to the
tissues (central venous oxygen saturation <70%, mixed venous oxygen saturation <65% or lactate
concentration >4 mmol/L), blood transfusion is considered to achieve a target Hb of 9-10 g/dl.
In the later phases of severe sepsis, the guidelines are similar to those for other critically ill patients with
target Hb of 7-9 g/dl.
Caveat : Blood transfusion should not be used to assist weaning from mechanical ventilation if the Hb is
>7 g/dl.
Rationale & Trigger for Transfusion in different clinical settings

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Patients with cardiac disease
In haemodynamically stable patients with cardiovascular disease transfusion is considered for Hb ≤ 8
g/dl, or the presence of symptoms of inadequate oxygen delivery.
In critically ill patients with stable angina, Hb should be maintained >7 g/dl. Transfusion to a Hb of >10
g/dl has uncertain benefit.
In patients suffering from acute coronary syndrome, Hb should be maintained at >8-9 g/dl.
Caveat : Restrictive transfusion strategy (trigger Hb: 7-8 g/dl) is recommended for patients with
coronary artery disease.
Patients with neurotrauma or neurological diseases
In patients with traumatic brain injury, the target Hb should be 7-9 g/dl; and in those with
additional evidence of cerebral ischaemia the target Hb should be >9 g/dl.
In patients with subarachnoid haemorrhage the target Hb should be 8-10 g/dl.
In patients with an acute ischaemic stroke the Hb should be maintained above 9 g/dl.
Rationale & Trigger for Transfusion in different clinical settings

17. 17• Transfusion of blood products carries risks similar to those of RBC transfusion.
• In fact, some of risks, as Acute Lung Injury(TRALI) occur more often with transfusion of
plasma(FFPs).
• Plasma is conventionally prescribed to replace coagulation factors in patients receiving massive
transfusion (70 ml/kg in 24 h or >50% of blood volume in 3 h), for urgent reversal of the effect of warfarin,
in known coagulation factor deficiency, and in cases of thrombotic thrombocytopaenic purpura. Decision
to transfuse is based on both presence of bleeding and abnormal laboratory values of PT (>1.5 times), INR
(>2) and aPTT(>2 times). Caveat : Plasma should not be used to replace intravascular volume.
• Platelet transfusion is usually required in a bleeding patient below a platelet count of 50 × 10 9 /L but
rarely above 100 × 10 9 /L.
Caveat : Values between 50 & 100 x 10 9 /L, transfusion is considered in case of platelet
dysfunction (e.g. clopidogrel therapy), on-going bleeding and surgeries in confined
spaces such as eye and brain.
• Cryoprecipitate is used to increase fibrinogen levels in patients with dysfibrinogenaemia and
hypofibrinogenaemia (fibrinogen <80-100 mg/dl), microvascular bleeding in patients receiving massive
transfusion.
Rationale & Trigger for Transfusion in different clinical settings

18. Blood products Start transfusion Complete transfusion
Whole blood / PRBC Within 30 minutes of
removing from
refrigerator
≤ 4 hours
Platelet concentrate Immediately Within 30 minutes
FFP As soon as possible Within 30 minutes
Cryoprecipitate As soon as possible Within 30 minutes
NOTE- Always Administer Platelets, FFP, Cryo before a Red Cell Transfusion
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Transfusion Guidelines

19. Transfusion Guidelines
19
Shifting of blood groups among available blood components.
•Shifting blood groups for PRBC due to Non-availability of Specific group
• Rh D Negative female in fertility period patient should be transfused only Rh D Negative PRBC.
• Rh D Positive male patient /elderly female without anti D alloantibodies can be transfused Rh D Negative PRBC in
emergency with consent
Patient
Blood
Group
Donor
group
1st
choice
2nd
choice
3rd
choice
4th
choice
O O - - -
A A O - -
B B O - -
AB AB B A O

20. Patient
Blood
Group
Donor
group
1st
choice
2nd
choice
3rd
choice
4th
choice
O O AB A B
A A AB - -
B B AB - -
AB AB - - -
20Shifting blood groups for FFP due to Non-availability of Specific group
• Rh D Negative patient can be transfused Rh D Positive FFP due to absence of antigen and
antibody in the component
Transfusion Guidelines

21. Patient
Blood
Group
Donor
group
1st
choice
2nd
choice
3rd
choice
4th
choice
O O - - -
A A O - -
B B O - -
AB AB B A O
21Shifting blood groups for RDP due to Non-availability of Specific group
In case of emergency ABO incompatible RDP can be transfused.
Rh D Negative female within child bearing age should be transfused only Rh D Negative RDP to prevent Rh D
isoimmunisation.
Rh D Negative male and post-menopausal female patient can be transfused Rh D positive RDP.
Rh D positive patient can be transfused Rh D Negative RDP.
Transfusion Guidelines

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Transfusion Guidelines

23. Cryoprecipitate
It can be transfused irrespective of ABO and RH (D) status
due to absence of antigen and antibody in the
component.
23
Transfusion Guidelines

24. Leukocyte-Reduced Red Blood Cells
Description:
Packed red cells with leukocytes reduced
(residual leukocyte count less than 5 X 106)
Product made during transfusion with filter
attached to unit
(residual leukocyte count less than 3 X 106)
Indications:
1. Prevention of HLA/WBC alloimmunization
2. Prevention of recurrent non-hemolytic febrile
reactions
3. Prevention of CMV transmission in select
groups of patients
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25. Irradiated Blood Products
(Leukodepleted)
A. Products irradiated: Whole blood, packed red cells, platelets
and granulocyte concentrates
B. Indications: preventing graft versus host disease
1. Immunocompromised patients
2. Directed donations from blood relatives
3. Premature infants ≤ 1200 gm Fetuses receiving intrauterine
transfusions
4. Neonatal exchange transfusions
C. Processing and final product:
1. Irradiate with 2500 rads (25Gy) with gamma rays for 15-
20min
2. Mitotic capacity of lymphocytes is reduced or eliminated
without significant functional damage to other cellular
elements
D. Storage:
Red cells outdate 28 days from irradiation (or original
expiration if less than 28 days) whichever comes first.
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Use of blood bag labels (Gamma Irradiation
Indicator)- RadTag indicators meeting international
guidelines for blood irradiation.
sensitive in identifying if blood has been under-
irradiated (less than 25Gy) or over irradiation (over 50
Gy)

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• It provides continuous monitoring of the
clotting process of whole blood from its
steps of initiation, amplification,
propagation, and termination through
fibrinolysis, generating parameters and
producing values related to each step
• Hemorrhagic shock is associated with an
intrinsic coagulopathy, TEG has been used
as a method of diagnosing specific
coagulation defects in order to direct
individualized blood products
resuscitation.
• An alternative transfusion strategy as Goal
directed product instead of Fixed
ratio(1:1:1) product administration.

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29. Oral antiplatelet therapy: impact for transfusion medicine.
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Patients on antiplatelet therapy- may develop bleeding or need transient reversal of platelet blockade
for acute interventions.
Antiplatelet Drugs - Aspirin only, or Aspirin in combination with oral adenosine diphosphate (ADP)
receptor (P2Y12 receptor) inhibitors like clopidogrel, prasugrel and ticagrelor
Platelet inhibition due to clopidogrel, and to some extent also prasugrel may be overcome by platelet
transfusion, but large clinical data on these patients are lacking. Ticagrelor-mediated platelet inhibition
remains a challenge, case reports show that platelet transfusion did not restore haemostasis.
Prescription of the latter therefore demands a particular stringent indication.
Platelet Mapping - an additional technology in the TEG system that
measures platelet function in the presence of antiplatelet therapy. TEG
Platelet Mapping compares standard TEG results (MA) in fully activated
blood—where thrombin causes full platelet activation—with TEG results
(MA) from blood activated with a combination of snake venom and a weak
platelet agonist such as ADP or arachidonic acid (the venom converts
fibrinogen to fibrin) and presents it as percentage inhibition/aggregation.
Suggested Interpretation- %Inhibition- <30% less likely to bleed, 30-60%
moderate risk to bleed, >60% high risk to bleed

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