# Blood Transfusion

## Overview

This module describes how to order and transfuse blood products safely to prevent potentially fatal transfusion reactions.

## Indications

Although the decision to transfuse blood products should be individualised, the Clinical Guidelines for the Use of Blood Products in South Africa recommend:

1. Red cell components:

   1. Acute blood loss > 30% of blood volume
   2. Pre-operative Hb < 8 g/dl where blood loss > 500 ml is expected
   3. Intra- or postoperative Hb < 7 g/dl
   4. Hb < 8 g/dl in acute coronary syndromes
   5. Hb < 8 g/dl with symptoms of anaemia
   6. Hb < 6 g/dl in patients with obstetric haemorrhage

2. Whole blood

   1. Exchange transfusions in neonates
   2. Massive haemorrhage

3. Platelets

   1. Patients with active, severe bleeding and thrombocytopenia
   2. Prophylactically in some cases of severe thrombocytopenia
   3. Given with massive infusions

4. Fresh frozen plasma

   1. Inherited clotting factor deficiencies
   2. Acquired clotting factor deficiencies such as DIC and liver disease with active bleeding
   3. Reversal of warfarin overdose
   4. Thrombotic thrombocytopenic purpura
   5. Vitamin K deficiency with active bleeding
   6. Suxamethonium apnoea
   7. Given with massive infusions

Massive infusions (more than 10 units in 24 hours) generally involve giving packed red cells, platelets and fresh frozen plasma in a 1:1:1 ratio.

## Contraindications

1. Informed

   refusal
   refusal

   Consent is commonly refused by Jehovah's Witness patients. Contact the Jehovah's Witness Hospital Liaison Committee (083 226 5959) for information on alternative options to treat these patients.

   If Jehovah's Witness parents refuse blood transfusion for their child, a court order may be necessary to overturn their refusal. Contact your hospital leadership in these cases.

   of blood product transfusion

2. Red cell components

   - Compensated chronic anaemias such as nutritional anaemias

3. Platelets

   - Autoimmune thrombocytopenia, thrombotic thrombocytopenic purpura, or heparin-induced thrombocytopenia

## Patient information & consent

Always verify your patient’s identity and obtain written informed consent before proceeding.

### How do I explain this procedure?

“I need to give you some blood, because [explain the indication]. This blood has been matched to be similar to yours, and has been checked in the laboratory to be safe for you to receive. It’s important that you understand and agree to the transfusion. The law requires that you sign a consent form.”

### What can my patient expect?

“I will put up a drip and give you the blood over a few hours. It will sting when I prick your skin with the needle, but receiving the blood itself does not hurt.”

### What is my patient’s role?

“Let me know if you have any allergies or medical conditions. Fearing blood or needles is normal, but tell me if you have fainted from it. It is very rare for patients to get a reaction to the blood, but let the staff know immediately if you start to feel strange or unwell.”

## Preparation

1. Confirm the identity of the patient and draw a blood sample for group and

   crossmatch, or group and screen
   crossmatch, or group and screen

   In a crossmatch, full blood group and antibody compatibility are tested, after which the blood is sent to the requester.

   In a group and screen, the blood group and the presence of atypical antibodies is determined. The blood is kept at the blood bank and only crossmatched and sent if requested. This option is chosen most often by surgeons when there is a small possibility of blood loss during a procedure.

   .

2. Complete the blood bank requisition forms in duplicate and take them with the blood sample to the blood bank.

3. Fetch the blood from the blood bank when it is ready. Take a patient label with you to confirm the patient’s identity with the blood bank staff.

4. Bring the

   blood hamper
   blood hamper

   The hamper is cooled to keep the blood at 6-10°C. The Western Cape Blood Service allows blood that has not been removed from the hamper to be returned within 24 hours. The South African National Blood Service only allows blood to be returned if it has been ordered on a returnable basis, and within 12 hours of receipt.

   to the patient’s bedside.

## Site & Positioning

See IV cannulation.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene.

2. Identify the patient. Two healthcare professionals should confirm that the same patient information is present on the blood unit, the papers from the blood bank, and the patient’s folder.

3. Check that the blood unit has no leaks or clots, is not expired, and is the correct product.

4. Insert an IV cannula,

   ideally 18 G.
   ideally 18 G.

   Use the largest size appropriate for the size of the patient's veins; no smaller than 20 G to allow a higher flow rate and lower risk of clotting.

   Be particularly meticulous about aseptic technique. Blood infusions are particularly vulnerable to bacterial colonisation, and blood is an excellent culture medium.

5. Take baseline observations before starting the infusion.

6. Prime
   Prime

   Close the clamps. Squeeze the chamber until the normal saline covers the filter. Open the clamps to allow saline to flush the entire line.

   an intravenous administration set with a blood filter using normal saline. Use a platelet giving set when administering platelets, but a blood giving set can also be used if a platelet giving set is not available. Close the roller clamp and detach the bag.

7. Tear off the port protector and attach the unit of blood to the administration set.

8. Start the infusion. Set the

   rate
   rate

   Depending on the patient's condition, massive haemorrhage requires rapid infusion, while chronic anaemia is limited to 2 ml/min.

   of the infusion.

9. Dispose of medical waste safely.

10. Write

    clear instructions
    clear instructions

    Prophylactic loop diuretics to prevent circulatory overload in patients at risk of pulmonary oedema is still used, but not routinely for every patient.

    for the nurses on the orders/prescription chart, specifically the name, volume and duration of the infusion. Vital signs should be recorded every 15 minutes for half an hour, then every 30 minutes for the duration of the transfusion. In cases of acute haemorrhage, observations should be continued every 15 minutes for the duration of the transfusion. Additionally, observe patients with cardiac or renal disease, who are at risk of circulatory overload, for 12-24 hours after the transfusion.

11. Record the completion of the procedure in patient notes.

## Troubleshooting

I’m unsure whether I should warm the blood.

It is not important to warm blood given slowly and in small volumes, but blood given to infants and in massive transfusions should be warmed in a blood warmer. Do not use a warm water bath or microwave to warm blood, because of the risk of haemolysing the outer layer of blood.

I’m unsure whether I can add antibiotics or other IV medications to the blood bag.

Do not add anything to a blood bag. If there is no other IV access available, you can add a Y-piece to the section of the administration set closest to the patient and infuse medication or fluids in this way.

I’m unsure how to recognise a transfusion reaction.

The patient may complain of chills, pain, shortness of breath, dizziness, a rash, or pruritis. The vital signs may be deranged, with tachycardia, pyrexia, tachypnoea, and hypotension. The patient may develop jaundice, anuria or haemoglobinuria. Severe reactions may present as anaphylaxis.

I’m unsure how to treat a transfusion reaction.

Stop the infusion and keep the IV access patent by using a new administration set with normal saline. Keep the blood and the old administration set. Contact the blood bank for advice.

## Risks

1. See Peripheral Venous Access
2. Transfusion reactions
3. Circulatory overload

## References

1. National Institute for Health and Care Excellence. Blood Transfusion (NG24). 2015. Available from: https://www.nice.org.uk/guidance/ng24
2. Western Cape Blood Service & South African National Blood Service. Clinical Guidelines for the Use of Blood Products in South Africa. 5th edition. 2014. Available from: https://www.wcbs.org.za/wp-content/uploads/2020/06/clinical_guidelines_5th-Edition_2014.pdf
3. Engelbrecht D. How To Give a Blood Transfusion. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 333-335.