This document discusses blood transfusion, including definitions, types of transfusions, blood products, indications for transfusion, risks, and guidelines. It covers topics like whole blood, packed red blood cells, platelets, plasma, and cryoprecipitate. Key points include that transfusion involves receiving blood products intravenously to replace lost blood, it can use one's own blood or from a donor, and decisions should be based on careful assessment of clinical and lab indications to save life or prevent morbidity.

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

7. 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.
•EACH UNIT OF BLOOD IS TESTED FOR EVIDENCE OF HEPATITIS-B,
HEPATITIS-C , HUMAN IMMUNODEFICIENCY VIRUS I & II AND
SYPHILIS.
•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.

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

10. • STORED BETWEEN +2 AND +6 DEGREES CENTIGRATE IN A BLOOD
BANK REFRIGERATOR.
•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.
INDICATIONS –
•RED CELL REPLACEMENT IN ACUTE BLOOD LOSS WITH
HYPOVOLAEMIA
•EXCHANGE TRANSFUSION
CONTRAINDICATIONS –
•CHRONIC ANAEMIA
•INCIPIENT CARDIAC FAILURE

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

14. 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.
•IT IS THE FIRST LINE THERAPY IN THE TREATMENT OF
COAGULOPATHIC HAEMORRHAGE.
•ALSO USED IN THE REPLACEMENT OF MULTIPLE COAGULATION
FACTOR DEFICIENCIES LIKE LIVER DISEASE, WARFARIN OVERDOSE,
DEPLETION OF COAGULATION FACTORS IN PATIENTS RECEIVING
LARGE VOLUME TRANSFUSIONS, DISSEMINATED INTRAVASULAR
COAGULATION AND THROMBOTIC THROMBOCYTOPENIC PURPURA.

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

16. Platelets
•PLATELETS ARE SUPPLIED AS A POOLED PLATELET CONCENTRATE
CONTAINING ABOUT 250 X 10 9 CELLS PER LITRE.
•PLATELETS ARE STORED ON A SPECIAL AGITATOR AND HAVE A SHELF
LIFE OF ONLY 5 DAYS.
•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.
•NOT INDICATED IN –
• PATIENTS WITH ITP, TTP, UNTREATED DIC AND IN CASES OF
HYPERSPLENISM.

17. •DOSAGE – 1 UNIT OF PLATELET CONCENTRATE /10 kg BODY WEIGHT.
•4-6 DONOR UNITS OF PLATELET CONCENTRATES WILL RAISE THE
PLATELET COUNT BY 20-40 X 109/L. INCREMENT WILL BE LESS IF THERE
IS ASSOCIATED SEPTICEMIA, DIC, SPLENOMEGALY.
•COMPLICATION S–
FEBRILE AND ALLERGIC URTICARIAL REACTIONS ARE COMMON
ESPECIALLY IN PATIENTS RECEIVING MULTIPLE TRANSFUSIONS.
• 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.

19. CRYOPRECIPITATE
•CRYOPRECIPITATE IS A SUPERNATANT PRECIPITATE OF FRESH
FROZEN PLASMA AND IS RICH IN FACTOR VIII AND FIBRINOGEN.
•IT IS STORED AT -30 DEGREES CENTIGRATE WITH A 2 YEARS SHELF
LIFE.
•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.
•POOLED UNITS CONTAINING 3-6 gms FIBRINOGEN IN 200-500 ml
RAISES THE FIBRINOGEN LEVEL BY APPROX. 1g/L.
•MUST BE INFUSED WITHIN 6 HOURS.

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

22. •THEREFORE, 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.
•RHESUS SYSTEM- THE RHESUS D ANTIGEN IS STRONGLY ANTIGENIC
AND IS PRESENT IN APPROXIMATELY 85% OF THE POPULATION.
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.

23. MAKING THE
DECISION FOR
BLOOD
TRANSFUSION

24. •IF USED CORRECTLY, BLOOD TRANSFUSION CAN BE LIFE-SAVING,
INAPPROPRIATE USE CAN ENDANGER LIFE.
•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.

25. minimising the need for blood
transfusion
•Preoperative planning-
•History and examination including surgical or bleeding history
•Full blood count, blood chemistry, coagulation,
•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,
anticoagulants
•Repeat full blood count
•Consider drugs to reduce bleeding (such as aprotinin)

26. 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

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

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

30. PERI-OPERATIVE RED BLOOD CELL
TRANSFUSION CRITERIA
HAEMOGLOBIN INDICATION
LEVEL g/dl
<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

31. Who Transfusion guidelines for chronic
anaemia during pregnancy
DURATION OF PREGNANCY HAEMOGLOBIN LEVEL CONSIDER IF-
<36 WEEKS 5.0 g/dl or LESS EVEN Hb 5.0-7.0g/dl + Established
WITHOUT CLINICAL SIGNS or incipient cardiac failure,
OF CARDIAC FAILURE OR Clinical evidence of hypoxia,
HYPOXIA Pneumonia or any serious
bacterial infections, Pre-
existing heart disease.
>36 WEEKS 6.0 g/dl OR LESS Hb 6.0 – 8.0 g/dl + Above
mentioned conditions
ELECTIVE CAESAREAN 8.0-10.0 g/dl- Confirm blood Elective CS Planned +
SECTION group, Save freshly taken History of APH, PPH,
serum for cross-matching. Previous CS.
<8.0 g/dl – 2 Units of blood
should be cross-matched
and available.

32. ESTIMATING BLOOD LOSS
•IN ORDER TO MAINTAIN BLOOD VOLUME ACCURATELY, IT IS
ESSENTIAL TO CONTINUALLY ASSESS SURGICAL BLOOD LOSS
THROUGHOUT THE PROCEDURE.
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, which is
4200 ml.
1. Weigh swabs while still in their dry state.
2. 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 the ungraduated drains or suction bottles and subtract
their empty weight.

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

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

35. SAFE
BLOOD
TRANSFUSION
PROCEDURES

36. • EVERY HOSPITAL SHOULD HAVE WRITTEN STANDARD OPERATING
PROCEDURES FOR THE ADMINISTRATION OF BLOOD PRODUCTS LIKE
THE ONE WE HAVE IN OUR HOSPITAL , PARTICULARLY FOR THE FINAL
IDENTITY CHECK OF THE PATIENT, THE COMPATIBILITY LABEL
DETERMINING THE PATIENT’S ABO AND RH-D GROUP, UNIQUE
DONATION NUMBER OF THE BLOOD PACK, BLOOD GROUP OF THE
BLOOD PACK, THE DATE OF COLLECTION AND THE EXPIRY DATE, THE
INDICATION FOR TRANSFUSION, 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.
•DISCOLOURATION OF THE BLOOD PACK AND ANY SIGNS OF LEAKAGE
INDICATE CONTAMINATION AND COULD CAUSE A SEVERE FATAL
REACTION IF TRANSFUSED.

37. DISPOSABLE EQUIPMENT FOR BLOOD ADMINISTRATION
• CANNULAS MUST BE STERILE AND MUST NEVER BE REUSED.
• FLEXIBLE PLASTIC CANNULAS SHOULD BE USED AS THEY ARE SAFER
AND PRESERVE THE VEINS.
FOR WHOLE BLOOD, RED CELLS, 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.
• IN A WARM CLIMATE, CHANGE THE SET MORE FREQUENTLY AND
USUALLY AFTER EVERY 4 UNITS OF BLOOD IF GIVEN WITHIN A 12
HOUR PERIOD.

38. • THERE IS NO EVIDENCE THAT WARMING BLOOD IS BENEFICIAL TO
THE PATIENT WHEN INFUSION IS SLOW. AT INFUSION RATES
>100ml/minute, COLD BLOOD MAY BE A CONTRIBUTING FACTOR
IN CARDIAC ARREST. HOWEVER, 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.
•BLOOD SHOULD ONLY BE WARMED IN A BLOOD WARMER THAT
HAVE A VISIBLE THERMOMETER AND AN AUDIBLE WARNING
ALARM AND SHOULD BE PROPERLY MAINTAINED.

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

41. MONITORING THE TRANSFUSED PATIENT
1. FOR EACH UNIT OF BLOOD TRANSFUSED, 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. AT EACH OF THESE STAGES, RECORD:
• PATIENT’S GENERAL APPEARANCE
• BLOOD PRESSURE, PULSE, RESPIRATORY RATE
• FLUID BALANCE – ORAL AND IV FLUID INTAKE & URINARY
OUTPUT.

42. 3. RECORD:
• TIME WHEN THE TRANSFUSION IS STARTED.
• TIME WHEN THE TRANSFUSION IN COMPLETED.
• VOLUME AND TYPE OF ALL PRODUCTS TRANSFUSED.
• BLOOD PACK NUMBERS.
• ANY ADVERSE EFFECTS.
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.

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