Table of Contents

1. Introduction
1.1 Principles of clinical transfusion practice
1.2 Safe blood
2. Screening of blood donations
2.1 Steps in blood screening
2.2 Blood safety in the hospital setting
2.3 Blood donor recruitment
2.4 Blood collection
3. Blood components
3.1 Whole blood
3.2 Red cell concentrates/packed red blood cells
3.3 Platelet concentrates
3.4 Fresh frozen plasma
3.5 Cryoprecipitated antihemophilic factor
4. Storage of blood components
5. Clinical transfusion procedure
5.1 Indications for blood transfusion
5.2 Transfusion trigger
5.3 Responsibility of attending physician
6. Administration of blood products
6.1 Blood request form
6.2 Blood samples
6.3 Red cell compatibility testing
6.4 Collection and receipt of blood
6.5 Performing the transfusion
6.6 Monitoring the transfusion
6.7 Documentation of the transfusion
6.8 Other aspects of transfusion
6.8.1 Warming blood
6.8.2 Use of medication at time of transfusion
6.8.3 Use of fresh blood
7. Adverse effects of transfusion
7.1 Guidelines for recognition and management of acute transfusion reactions
7.2 Investigating acute transfusion reactions
7.3 Hemolytic transfusion reaction
7.4 Bacterial contamination and septic shock
7.5 Transfusion associated circulatory overload
7.6 Anaphylactic reaction
7.7 Transfusion related acute lung injury
7.8 Delayed complications of transfusion
7.8.1 Delayed hemolytic transfusion reaction
7.8.2 Post‐transfusion purpura
7.8.3 Transfusion associated graft‐versus‐host disease
7.8.4 Delayed complications: transfusion transmitted infections
8. Massive blood transfusion
9. Transfusion in pediatrics
9.1 Top‐up transfusions
9.2 Exchange transfusion
9.3 Hemolytic disease of the newborn
9.4 ABO hemolytic disease of the newborn
9.5 Transfusion of platelets and FFP in pediatric patients
10. Blood Transfusion Services in Bangladesh

Acronyms
AHF Antihemophilic factor
APTT Activated partial thromboplastin time
DAT Direct antiglobulin test
DIC Disseminated intravascular coagulation
FFP Fresh Frozen Plasma
Hb Hemoglobin
HBV Hepatitis B virus
Hct Hematocrit
HCV Hepatitis C virus
HDN Hemolytic disease of the newborn
HIV Human immunodeficiency virus
ITP Idiopathic autoimmune thrombocytopenic purpura
MOHFW Ministry of Health and Family Welfare
MTP Massive transfusion protocol
PC Platelet concentrates
PRBC Packed red blood cells
PT Prothrombin time
PTT Partial thromboplastin time
SRO Statutory Regulation Order
TACO Transfusion associated circulatory overload
TA‐GVHD Transfusion associated graft‐versus‐host disease
TR Transfusion reaction
TRALI Transfusion related acute lung injury
TTIs Transfusion transmissible infections
TTP Thrombotic thrombocytopenic purpura
1. Introduction
It is well known that errors in blood transfusion practices can lead to serious consequences for
the recipient in terms of morbidity and mortality. The majority of errors occur due to incorrect
sampling of blood from a patient, fetching the wrong unit of blood for a patient and transfusing
blood inappropriately. These clinical transfusion guidelines describe protocols for the collection
of blood samples for blood grouping and cross matching, and for the collection, storage and
administration of blood and blood products. The guidelines provide a standardized approach to
transfusion so that the potential for errors is minimized and the administration of safe and
efficacious blood products in the health care setting is maximized. They also contain protocols
for the investigation and treatment of adverse transfusion reactions and provide guidelines for the
use of specialized blood products.

1.1 Principles of clinical transfusion practice

 Patient with acute blood loss should receive effective resuscitation (IV replacement fluids, O2
and other medication) immediately and the need for transfusion is estimated thereafter.
 Patient’s hemoglobin (Hb) value, although important, should not be the sole deciding factor
in the decision to transfuse blood. This decision should be supported by the need to relieve
clinical signs and symptoms and to prevent significant morbidity or mortality.
 Clinicians should be aware of the risk of transfusion transmissible infections in blood
products prescribed for patients.
 Transfusion should be prescribed only when the patient’s the benefits 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 respond immediately there
are signs of an adverse effect.

1.2 Safe blood

Blood for transfusion is considered safe when it is:
 Donated by a carefully selected, healthy donor
 Free from infections that could be harmful to the recipient
 Processed by reliable methods of testing, component production, storage and transportation
 Transfused only upon need and for the patient’s health and wellbeing

Quality and safety of blood and blood products must be assured throughout the process from the
selection of blood donors to the administration of blood into the patient. This is described in the
WHO Blood Safety Initiative:
 Establishment of a well‐organized blood transfusion service with quality system in all areas.
 Collection of blood only from voluntary non‐remunerated donors from low‐risk populations,
using rigorous procedures for donor selection.
 Screening of all donated blood for transfusion transmissible infections i.e. HIV, HBV, HCV,
syphilis and malaria.
 Good laboratory practice in all aspects of blood grouping, compatibility testing, screening,
component preparation and the storage and transportation of blood and blood products.
 Reduction of unnecessary transfusions through appropriate clinical use of blood and blood
products and the use of simple alternatives to transfusion when possible.
Transfusion of blood and products should be undertaken only to treat a condition that would
lead to significant morbidly or mortality and that cannot be prevented or managed effectively by
other means.
2. Screening of Blood Donations
Blood screening began in Bangladesh in 2000 at all hospital based blood transfusion centers. It is
the process that starts with the recruitment of safe blood donors and is followed by mandatory
screening for five transfusion transmissible infections (TTIs) which includes HIV, HBV, HCV,
syphilis and malaria. Testing for TTIs started under the purview of Safe Blood Transfusion Act
2002, which states that prior to transfusion, all blood and its products must undergo testing.
Objective of screening is to detect markers of infection, and prevent the release of infected blood
and blood components for clinical use. Assay selected for screening should be highly sensitive
and specific. Aim is to detect all possibly infected donations while minimizing wastage due to
false positive results. Reactive donations that are confirmed positive, or in which results are
indeterminate, should be discarded using methods in accordance ē standard safety precautions.

2.1 Steps in blood screening

 Physical screening
– Blood donor selection
– Self‐exclusion, deferral
 Laboratory testing
– Detection of infection markers; either antibody or antigen

2.2 Blood safety in the hospital setting

 Low risk blood donor recruitment
 Blood screening
 Rational use of blood

2.3 Blood donor recruitment

It is recommended to collect blood from non‐remunerated volunteer donors. The aim of using
selection guidelines for blood donors has two purposes: firstly, to protect donors from potential
harm which may occur as a direct result of the donation process; secondly, to protect recipients
of blood transfusion from adverse effects, such as transmission of infectious diseases or other
medical conditions and unwanted effects caused by medication taken by the donor.
In Bangladesh, donors are selected according the following important eligibility criteria:
 General appearance: prospective donor shall appear to be in good physical and mental health.
 Age: donors shall be 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.
 BP: systolic and diastolic pressures shall be normal (systolic: 100‐140 mm Hg and diastolic:
60‐90 mm Hg is recommended), without the aid of anti‐hypertensive medication.
 Temperature: oral temperature shall not exceed 37.5oC/99.5oF.
 Pulse: pulse shall be between 60 and 100 beats per minute and regular.
 Donation interval: the interval between blood donations shall be 3 to 4 months.

2.4 Blood collection

Donor should not be fasting before donation. If last meal was taken more than 4 hrs previously,
donor should be given something to eat and drink before donation. Blood flowing into the bag is
mixed with anticoagulant in a ratio of 1 : 7 (anticoagulant : blood). Total collection volume is
from 405‐495 mL and usually, a volume of 450 mL blood is donated, this being approximately
12% of total blood volume or 10.5 mL/kg body weight.
3. Blood Components
A blood component is a constituent of blood, separated from whole blood, such as:
 Red cell concentrate
 Plasma
 Platelet concentrate
 Cryoprecipitate, prepared from fresh frozen plasma; rich in Factor VIII and fibrinogen
A plasma derivative is made from human plasma proteins prepared under pharmaceutical
manufacturing conditions, such as:
 Albumin
 Coagulation factor concentrates
 Immunoglobulin
In Bangladesh, blood is generally collected in CPDA/CPDA1 blood bags that contain 63 mL
anticoagulant solution which provides shelf life for RBCs 35 days when stored at +2°C to +6°C.
For collection of blood components in Bangladesh, double or triple bags are used. Components
are prepared using a centrifuge, a piece of equipment that is available in most blood transfusion
departments of medical colleges.

3.1 Whole blood

 Description: 450 mL whole blood in 63 mL anticoagulant‐preservative solution of which Hb
will be approximately 1.2 g/dL & Hct 35‐45% ē no functional platelets or labile coagulation
factors (V and VIII) when stored at +2°C to +6°C.
 Infection risk: Capable of transmitting an agent present in cells or plasma which was
undetected during routine screening for TTIs, i.e. HIV, hepatitis B & C, syphilis and malaria.
 Storage: Between +2°C and +6°C in an approved blood bank refrigerator, fitted with a
temperature monitor and alarm.
 Indications:
 Red cell replacement in acute blood loss with hypovolemia.
 Exchange transfusion.
 Contraindications: Risk of volume overload in patients with:
 Chronic anemia.
 Incipient cardiac failure.
 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.

3.2 Red cell concentrates (RCC)/packed red blood cells (PRBC)

 Description: 150‐200 mL red blood cells from which most of the plasma has been removed.
Hb concentration will be approximately 20 g/100 mL (< 45 g per unit) and Hct 55‐75%.
 Infection risk: Same as for whole blood.
 Storage: Same as for whole blood.
 Indications: Replacement of red cells in anemic patients.

3.3 Platelet concentrates (PC)

 Description: PCs are prepared from units of whole blood that have not been allowed to cool
below +20°C. A single donor unit consists of 50‐60 mL plasma that should contain ≥ 55 
109 platelets.
 Unit of issue: PCs may be supplied as a pooled unit, i.e. platelets prepared from 4‐6 donor
units containing at least 240  109 platelets.
 Infection risk: Bacterial contamination affects about 1% of pooled units.
 Storage: PCs may be stored for up to 5 days at +20°C to +24°C. PCs require continuous
agitation during storage, on a platelet shaker and in an incubator that maintains required
storage temperature.
 Dosage: 1 unit of platelet concentrate/10 kg; for an adult of 60‐70 kg, 4‐6 single donor units
containing at least 240  109 platelets should raise the platelet count by 20‐40  109/L.
Increment will be less if there is splenomegaly, DIC or septicemia.
 Indications: Treatment of bleeding due to:
 Thrombocytopenia.
 Platelet function defects.
 Prevention of bleeding due to thrombocytopenia as in bone marrow failure.
 Contraindications:
 Idiopathic autoimmune thrombocytopenic purpura (ITP).
 Thrombotic thrombocytopenic purpura (TTP).
 Untreated DIC.
 Thrombocytopenia associated with septicemia, or in cases of hypersplenism.
 Use in bone marrow failure:
 Treatment of bleeding, thrombocytopenic patients.
 Prophylactic use in thrombocytopenic patients.
o Maintain platelet count > 10  109/L in non‐bleeding, non‐infected patient.
o Maintain platelet count >20 x 109/L in infected/pyrexial patient.
 Use in DIC: For acute DIC, where bleeding is associated with thrombocytopenia, maintain
platelet count above 20  109/L even in the absence of overt bleeding.
 Use in massive blood transfusion: Maintain platelet count > 50  109/L in patients receiving
massive transfusions (dilutional thrombocytopenia occurs when > 1.5  blood volume of
patient is transfused).
 Use in cardiopulmonary bypass surgery:
 Platelet function defects and thrombocytopenia often occur after cardiac bypass surgery.
Platelet transfusion is recommended for patients with bleeding not due to surgically
correctable causes (closure time provides global indication of platelet function).
 Prophylactic platelet transfusions are not required for all bypass procedures.
 Prophylaxis for surgery:
 Ensure platelet count is > 50  109/L for procedures such as lumbar puncture, epidural
anesthesia, insertion of indwelling lines, trans‐bronchial biopsy, liver biopsy, renal biopsy
and laparotomy.
 Maintain platelet count >100  109/L for neurological and ophthalmic surgery.
 Administration: Platelet concentrates after pooling should be infused as soon as possible
because of risk of bacterial proliferation. Depending on the condition of the recipient, a unit
should be infused over a period of not more than 30 minutes. Do not give platelet
concentrates prepared from RhD positive donors to RhD negative female with childbearing
potential. Give platelet concentrates that are ABO compatible, whenever possible.
 Complications: Febrile non‐hemolytic and allergic urticarial reactions are not uncommon,
especially in patients receiving multiple transfusions.

3.4 Fresh Frozen Plasma (FFP)

 Description: FFP is plasma prepared from whole blood, either from primary centrifugation
of whole blood into red cells and plasma or from a secondary centrifugation of platelet rich
plasma. Plasma is rapidly frozen to –25°C or colder within 8 hours of collection and contains
normal plasma levels of stable clotting factors, albumin, immunoglobulin and Factor VIII at
a level of at least 70% of normal fresh plasma.
 Unit of issue: 200‐300 mL.
 Infection risk: Capable of transmitting any agent present in cells or plasma which was
undetected by routine screening TTIs, including HIV, hepatitis B and C, syphilis and malaria.
 Storage: FFP is stored at –25°C or colder for up to 1 year. Before use, it should be thawed in
the blood transfusion centre between +30°C and +37°C.
 Definite indications:
 Replacement of a single coagulation factor deficiency, where a specific or combined
factor concentrate is unavailable or contraindicated.
 Immediate reversal of warfarin effect where prothrombin complex concentrate is
unavailable.
 Thrombotic thrombocytopenic purpura.
 Inherited coagulation inhibitor deficiencies where specific concentrate is unavailable.
 C1 esterase inhibitor deficiency where specific concentrate is unavailable.
 Conditional indications:
 Massive blood transfusion.
 Acute DIC if there are coagulation abnormalities and patient is bleeding.
 Liver disease, with abnormal coagulation and bleeding – prophylactic use to reduce
prothrombin time (PT) to 1.6‐1.8  normal for liver biopsy.
 Cardiopulmonary bypass surgery – use in the presence of bleeding but where abnormal
coagulation is not due to heparin. Routine perioperative use is not indicated.
 Severe sepsis, particularly in neonates (independent of DIC).
 Plasmapheresis.
 Precautions:
 Acute allergic reactions are not uncommon, especially with rapid infusions.
 Severe life‐threatening anaphylactic reactions occasionally occur.
 Dosage: 15 mL/kg.
 Administration:
 Should be ABO compatible.
 Infuse as soon as possible after thawing.
 Labile coagulation factors rapidly degrade; use within 6 hours of thawing.
 FFP may be beneficial if PT and/or PTT > 1.5 times normal.
 FFP for volume expansion carries a risk of infectious disease transmission and other
transfusion reactions (e.g. allergic) that can be avoided by using crystalloid or colloid
solutions.

3.5 Cryoprecipitated anti‐hemophilic factor (Cryo‐AHF)

 Description: Cryo‐AHF is prepared from FFP by collecting the precipitate formed during
controlled thawing at +4°C and re‐suspending in 10‐20 mL plasma. It is stored at –25°C or
colder for up to 1 year after the date of phlebotomy. Cryo‐AHF contains about half the Factor
VIII and fibrinogen as a pack of fresh whole blood: e.g. Factor VIII: 80‐100 IU/ pack;
fibrinogen: 150‐300 mg/ pack.
 Infection risk: As for plasma, but a normal adult dose involves at least 6 donor exposures.
 Storage: At –25°C or colder for up to 1 year.
 Indications: As an alternative to Factor VIII concentrate in the treatment of inherited
deficiencies of:
 von Willebrand Factor (von Willebrand disease).
 Factor VIII (hemophilia A).
 As a source of fibrinogen in acquired coagulopathies; e.g. DIC.
 Can be used in isolated Factor XIII deficiency.
 Ameliorate platelet dysfunction associated with uremia.
 Used topically as a fibrin sealant.
 Administration:
 ABO compatible product should be used.
 After thawing, infuse as soon as possible.
 Must be transfused within 6 hours of thawing.
4 Storage of blood components
Blood must not be stored in a ward refrigerator under any circumstances.

Figure 1: Blood cold chain from collection to transfusion

5 Clinical Transfusion Procedure

5.1 Indications for blood transfusion

 To increase the oxygen capacity of blood by giving red cells.
 To restore the blood volume to maintain effective tissue perfusion.
 To replace platelets, coagulation factors and other plasma proteins.
Blood may be needed in the following circumstances:
 Blood loss:
o Bleeding
o Trauma
 Inadequate production:
o Diseases such as thalassemia, leukemia
 Excessive destruction of cells:
o Disease
o Mechanical
Transfusion of blood and products should be undertaken only to treat a condition that would
lead to significant morbidly or mortality that cannot be prevented or managed effectively by
other means.
Blood is more often needed under the following circumstances:
 Maternity: Women during pregnancy and at the time of delivery.
o Anemia of pregnancy; bleeding in pre‐ or post‐partum stage of delivery.
 5‐29 years: Vulnerability during this age range due to infancy on one hand (e.g. malnutrition,
malaria) and youth on the other (e.g. nature of work which may be more physical and more
likely to expose individual to accidents).
 Patients with chronic blood disease e.g. thalassemia, leukaemia.

5.2 Transfusion trigger (adults)

 One unit of whole blood/PRBC can increase Hb by 1g/dL in an adult or Hct by 3% (Hb of
unit must be >75%).
 Perioperative transfusion:
o 8 g/dL for patient undergoing cardiovascular/orthopedic surgery and acute GI bleeding.
 Chronic anemia: 7g/dL in adults.
 Acute blood loss: 30% of volume of blood.

5.3 Responsibilities of attending physician

 Assess patient’s clinical need for blood, and when required.
 Inform patient and/or relatives about proposed transfusion and record in patient’s notes.
 Also record indications for transfusion in patient’s notes.
 Select blood product and quantity required (i.e. whole blood/PRBC/FFP/PC) and complete
request form accurately and legibly.
 Enter the reason for transfusion on the form, so that the blood centre can check that the
product ordered is the most suitable with regard to diagnosis.
 Obtain and correctly label a blood sample for compatibility testing.
 Send the blood request form and blood sample to the blood bank.
 When the blood product that was ordered arrives, transfuse it as soon as possible to avoid
having to store it. However, if blood product is not used immediately, store it under correct
storage conditions.
 Cross check the identity of the patient and the blood product:
o Patient and documentation.
o Blood/blood products.
6 Administration of Blood Products
When blood is transfused, it is important to keep detailed records including following in
patient’s notes:
 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 responsible for administration of the blood.
 Monitor the patient before, during and on completion of the transfusion.
 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.
The process starts with 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.

6.1 Blood request form

When blood is required for transfusion, the prescribing clinician should complete and sign a
blood request form that is designed to provide all necessary information. All details requested on
the blood request form must be completed accurately and legibly.
 Blood request form should always be accompanied by patient’s blood sample. The sample is
placed in a sample tube that is correctly labeled and is uniquely identifiable with the patient.
 Blood sample shall not be submitted in a syringe, as this could lead to errors when
transferring to a test tube for grouping and compatibility testing. It may also cause hemolysis.
 For a routine case, sample and request form should be submitted to transfusion department at
least 24 hours before required, to make sure of the availability of blood.
 Physicians may request those, who accompany the patient, to consider becoming blood
donors if they are healthy and lead a healthy lifestyle.

6.2 Blood samples

Taking of a blood sample from patient needs supervision. If the patient is conscious at the time
of taking the sample, ask him/her to identify himself/herself by given name and all other
appropriate information.
A 5 mL blood sample should be collected into a dry test tube and then correctly and clearly
labeled with the patient’s details, and submitted to the blood centre for testing.
Specimen label must include the following information:
 Patient’s full name, age and sex.
 Registration number.
 Ward/bed number.
 Date and time specimen taken.
 Phlebotomist’s signature/initials.
o Use positive patient identification to identify the patient. NEVER pre‐label the sample
tube before phlebotomy.
o Use the blood product request form, write legibly and fill in all appropriate details.
o When taking a blood sample for cross match, complete whole procedure before any other
task is undertaken – it is important that there are no interruptions during the process.
 o Signature of the individual who took the sample must appear on the specimen label.
Retention of blood samples:
 Blood samples from recipient and donor(s) must be retained for 7 days at +2°C to +8°C after
each transfusion.
 Should another transfusion be necessary 72 hours after the earlier transfusion, a fresh sample
shall be requested for cross match. Collection of a second 5 mL blood sample is required for
rechecking and further cross matching and must be retained in case of investigation of
transfusion reaction.

6.3 Red cell compatibility testing

Laboratory performs:
 ABO and RhD grouping on patient and donors.
 Antibody screening on patient.
 Cross matching between serum of patient and red cells of donor.
These procedures normally take about an hour or more to complete. Shortened procedures are
possible in case of emergency, but may fail to detect some incompatibilities.
 The term compatibility test and cross match are sometimes used interchangeably; they should
be clearly differentiated.
 The cross match is the part of pre‐transfusion test known as compatibility testing.
 The compatibility test includes:
o ABO and RhD grouping of donor and recipient.
o Screening for unexpected antibodies on donor and patient.
o Cross match.
All pre‐transfusion test procedures should provide information on ABO and RhD grouping of
both patient and units of blood to be transfused.
Purpose of compatibility testing:
 To select blood components that will cause no harm to the recipient and will have acceptable
survival rates when transfused.
 When correctly performed, compatibility tests will confirm ABO compatibility between
component & recipient and will detect the most clinically significant unexpected antibodies.
 Compatibility (cross match) must be performed before blood is transfused. The cross match
is incompatible if there is a reaction between the patient’s serum and donor’s red cells.

6.4 Collection and receipt of blood

 ALWAYS take a completed patient documentation label to the issue room of the blood
transfusion department when collecting the first unit of blood.
 MATCH the details on the blood request form against the blood compatibility label (tag), the
bag unit number and the patient documentation label.
 If everything matches, sign out the unit with the date and time.
 If there is any discrepancy, DO NOT sign out the unit; contact the staff member of the blood
transfusion department immediately.
 When receiving the unit of blood in the clinical area, check that it is the right unit for the
right patient.
Always check patient/component compatibility/identity. Inspect pack & contents for signs of
deterioration or damage.
Figure 2: Check points for signs of deterioration in blood and plasma

Discoloration or signs of any leakage may be the only warning that the blood has been
contaminated by bacteria and could cause a severe or fatal reaction if transfused.
Blood bag should be checked for:
 Any sign of hemolysis in plasma indicating that the blood has been contaminated, allowed to
freeze or to warm.
 Any sign of hemolysis on the line between the red cells and plasma during storage.
 Any sign of contamination e.g. change of color in RBC, which often look darker/purple/black
when contaminated.
 Any clot, which may mean that the blood was not mixed properly with the anticoagulant
when it was collected or might also indicate bacterial contamination due to utilization of
citrate by proliferating bacteria.
 Any sign that there is a leak in the bag or that it has already been opened.
The blood unit must be discarded if:
 It has been out of the refrigerator for longer than 30 minutes, or
 The seal is broken, or
 There is any sign of hemolysis, clotting or contamination.

6.5 Performing the transfusion

Once issued by blood centre, the transfusion of whole blood, red cells, platelet concentrate and
thawed fresh frozen plasma should be commenced within 30 minutes of removal from optimal
storage conditions.
If the transfusion cannot be started within this period, the unit(s) must be stored under approved
optimal storage conditions. The temperature inside every blood bank refrigerator used for whole
blood/ red cell storage should be monitored and recorded daily to ensure that the temperature
remains between +2°C and +6°C. If the ward or operating room does not have a blood bank
refrigerator that is appropriate for storing blood, the blood should only be released from the
blood centre just before transfusion.
 Checking the patient’s identity and the blood bag before transfusion: Before starting
transfusion, it is vital to make final identity check in accordance with the hospital’s standard
operating procedure. Final identity check should be undertaken at the patient’s bedside
immediately before commencing the administration of the blood product. It should be
undertaken by two people, at least one of whom should be a registered nurse or doctor. Final
 check at the patient’s bedside is the last opportunity to detect an identification error and
prevent a potentially incompatible transfusion, which may be fatal.
 Suggested rate of transfusion: Transfusion rate depends on clinical circumstances and may
vary from 3‐5 mL/kg/hour to greatly increased rates for individuals in hypovolemic shock.
Table-1: Suggested rates of transfusion
Adults Rate Pediatric patients Rate
Whole blood 150‐200 mL/hour Whole blood/PRBC 2‐5 mL/kg/hour
PRBC 100‐150 mL/hour Platelets/plasma 1‐2 mL/minute
Platelets/plasma 150‐300 mL/hour
 Time limits for transfusion:
 There is a risk of bacterial proliferation or loss of function in blood products once they
have been removed from the correct storage conditions.
 Transfusion of a unit of blood should be completed within a maximum period of four
hours after removal from the blood fridge: discard the unit if this period is exceeded.
 If blood has been out of blood bank refrigerator for more than 30 minutes and is not
transfused, then the unit must be returned to the laboratory, where it will be disposed of.
Table-2: Duration times for transfusion
Blood products Start transfusion Complete transfusion
Whole Within 30 minutes of ≤ 4 hours
blood/PRBC removing from refrigerator Discard unit if this period is exceeded
Platelet Immediately Within 30 minutes
concentrate
FFP As soon as possible Within 30 minutes
Cryoprecipitate As soon as possible Within 30 minutes
 Blood administration set:
 Use a new, sterile blood administration set containing an integral 170‐200 μ filter.
 Change the set at least 12‐hourly during blood transfusion.
 In a very warm climate, change the set more frequently and usually after every four units
of blood, if given within a 12‐hour period.
 Use a fresh blood administration set or special platelet transfusion set, primed with saline.
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, e.g. 14 G, are needed.

6.6 Monitoring the transfusion

 It is essential to take baseline observations and to ensure that the patient is monitored during
the transfusion in order to detect any adverse event as early as possible. Before commencing
transfusion, it is essential to encourage patient to notify a nurse or doctor immediately if he
or she becomes aware of any discomfort such as shivering, flushing, pain or shortness of
breath or begins to feel anxious.
 Ensure that the patient is in a setting where he or she can be directly observed.
 For each unit of blood transfused, monitor the patient:
o Before starting the transfusion (baseline observation).
o 15 minutes after starting the transfusion.
o At least every hour during transfusion.
o Carry out a final set of observations 15 minutes after each unit has been transfused.
6.7 Documentation of the transfusion
Monitor the patient before, during and on completion of the transfusion.
 At each of these stages, record the following information on the patient’s chart:
o Patient’s general appearance.
o Temperature.
o Pulse.
o Blood pressure.
o Respiratory rate.
 Make note of the following:
o Time the transfusion started.
o Time the transfusion was completed.
o Volume and type of blood products transfused.
o Unique donation number of all products transfused.
o Any adverse effect.
 Record in the patient’s notes:
o Type and volume of each unit transfused.
o Unique donation number of each unit transfused.
o Blood group of each unit transfused.
o Time at which the transfusion of each unit commenced.
o Signature of the individual responsible for administration of the blood.
o Record the time of completion of the transfusion.
o Record the details of transfusion reaction.
 Identify and respond immediately to any adverse effect, by stopping the transfusion.
Severe reactions most commonly present during the first 15 minutes of a transfusion. All patients
and in particular, unconscious patients should be monitored during this period and for the first
15 minutes of each subsequent unit.
Specific instructions concerning possible adverse events shall be provided to the patient.
The transfusion of each unit of the whole blood or red blood cells should be completed within
four hours of the start of the transfusion. If a unit is not fully transfused within four hours,
discontinue its use and dispose of the remainder through the clinical waste system.
Check that the following information has also be recorded in the patient’s notes:
 Whether the patient and/or relatives were informed about the transfusion.
 The reason for transfusion.
 Signature of the prescribing clinician.
 Pre‐transfusion checks of:
o Patient’s identity.
o Blood bag.
o Compatibility label.
o Signature of individual performing the pre‐transfusion identity check.
 The transfusion:
o Type and volume of each product transfused.
o Unique donation number of each unit transfused.
o Blood group of each unit transfused.
o Time at which the transfusion of each unit commenced.
o Signature of the person administering the blood component.
o Monitoring of the patient before, during and on completion of transfusion.
 o All other details related to the transfusion process.
o Informed consent.
o Administration of the unit.
o Set‐up time of each unit transfused.
o Time of transfusion.

6.8 Other aspects of transfusion

6.8.1 Warming blood: There is no evidence that warming blood is beneficial to patient when
transfusion is slow. At transfusion rates of > 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:
o Adults: more than 50 mL/kg/hour.
o Children: more than 15 mL/kg/hour.
 Exchange transfusion in infants.
 Patients with clinically significant cold agglutinins.
o Blood should only be warmed in a blood warmer. Blood warmers should have a visible
thermometer and an audible warning alarm and should be properly maintained.
o 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.

6.8.2 Use of medication at time of transfusion: It is generally not recommended to routinely

use pre‐medication like anti‐histamines, steroids or other medication before transfusion. This
practice may mask or delay the signs and symptoms of an acute transfusion reaction and
therefore delay recognition and 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 same line as blood and blood
components. Exception is normal saline (0.9% sodium chloride) which may be used in
special circumstances, e.g. when the flow is slow due to increased Hct, or when saline is used
to prepare washed red cells.
 Use a separate intravenous line if an intravenous fluid has to be given at the same time as
blood transfusion.

6.8.3 Use of fresh blood: Stored blood less than 7 days old is termed as fresh blood. Uses (to
avoid biochemical overload) to raise Hb:
 Renal and liver dysfunction.
 Patient requiring massive blood transfusion.
 Patient with raised plasma potassium due to extensive burns, or intravascular hemolysis.
 Neonate requiring exchange transfusion.
There is no justification in transfusing whole blood to stop bleeding due to coagulopathies in
adults, as it does not contain sufficient viable platelets, or fibrinogen, or other coagulation
factors. To stop bleeding, specific component is needed. FFP, PCs or cryoprecipitate, are the
treatments of choice to stop bleeding.

6.8.4 Disadvantages of using blood that has not been stored between +2°C and +6°C:
 Increased risk of disease transmission:
o Intracellular pathogens (CMV, HTLV) survive in leukocytes present in fresh blood.
o Syphilis transmission: Treponema should not survive > 96 hours in stored blood.
o Malaria transmission: malarial parasite should not survive > 7 hours in stored blood.
7 Adverse Effects of Transfusion
 Very first step is to stop the transfusion immediately. If the reaction is severe, the needle
should be removed to prevent any further transfusion of blood.
 All suspected acute transfusion reactions should be reported immediately to the blood
transfusion centre and to doctor responsible for the patient. With the exception of urticarial
allergic reactions and febrile non‐hemolytic reactions, all are potentially fatal and require
urgent treatment.
 Acute reactions may occur in 1-2% transfused patients. Rapid recognition and management
of the reaction may save the patient’s life. Once immediate action has been taken, careful and
repeated clinical assessment is essential to identify and treat the patient’s problems.
 Errors and failure to adhere to correct procedures are the common causes of life‐threatening
acute hemolytic transfusion reactions.
 Bacterial contamination in red cells or platelet concentrates is an under‐recognized cause of
acute transfusion reaction.
 Patients who receive regular transfusions are particularly at risk of acute febrile reactions.
These should be recognized so that transfusion is not delayed or stopped unnecessarily.
 Transfusion transmitted infections are the serious delayed complications of transfusion. Since
a delayed transfusion reaction may occur days, weeks or months after the transfusion, the
association with the transfusion may not be recognized.
 Transfusion of a large volume of blood and intravenous fluids may cause haemostatic defects
or metabolic disturbances in the patient. There should be an availability of various treatments
including oxygen, adrenaline, corticosteroids, bronchodilators, diuretics and an emergency
team. In an unconscious or anaesthetized patient, hypotension and uncontrolled bleeding may
be the only sign of an incompatible (mismatched) transfusion.
In a conscious patient undergoing an acute severe hemolytic transfusion reaction, signs &
symptoms may appear within minutes of transfusion of 5‐10 mL of blood. Close observation at
the start of the transfusion of each unit is therefore essential.

Figure 3: Hazards of blood transfusion

Transfusion reaction

Acute Delayed

Immunological Non-immunological Immunological Non-immunological

 Hemolytic  Bacterial  Hemolytic  Transfusion
 Febrile non contamination  Transfusion induced
hemolytic  Circulatory related host-vs- hemosiderosis
 Allergic overload graft disease  Disease
 Transfusion  Physical or  Post-transfusion transmission
related acute chemical purpura
lung injury hemolysis
(TRALI)

Transfusion reaction (TR):

 Acute TR (<24 hours):
 o Wrong blood, primed immunological recipient
o Poor quality blood, faulty assessment
 Delayed TR (>24 hours):
o Diseases, other delayed immunologic reactions, metabolic effect (5‐10 days)

Investigation of a suspected TR: TRs may be acute or delayed. Acute reactions range from
non‐specific febrile episode to life-threatening intravascular hemolysis. All suspected transfusion
reactions should therefore be assessed and treated appropriately.
 If an acute transfusion reaction is suspected, stop the transfusion immediately.
 Check the blood bag label against the patient’s identity.
 If the reaction is severe or misidentification is confirmed on checking, remove the needle.
 If the reaction is mild, keep the IV line open with an infusion of 0.9% sodium chloride.
 At the same time, call for assistance; notify blood bank and senior in charge of the ward.
With the exception of urticarial allergic and febrile non‐hemolytic reactions, all are potentially
fatal and require urgent treatment. The severity of the reaction and the degree of morbidity is
usually related to the volume of blood transfused. The only sign in an unconscious or
anesthetized patient may be hypotension and uncontrolled bleeding or oozing. In a conscious
patient this may occur within minutes of transfusion of as little as 5‐10 mL blood.

7.1 Guidelines for recognition and management of acute transfusion reactions

Table 3: Category 1—Mild reactions
Signs Symptoms Possible cause
Localized cutaneous: Pruritus Hypersensitivity (mild)
Urticaria
Rash
Immediate management of Category 1—Mild reactions:
 Slow the transfusion.
 Administer antihistamine IM.
 If no clinical improvement within 30 minutes or if signs and symptoms worsen, treat as
Category 2. If improved, restart transfusion slowly.

Table 4: Category 2—Moderately severe reactions

Signs Symptoms Possible cause
Flushing Anxiety Hypersensitivity
Urticaria Pruritus
Rigors Palpitations
Fever Mild dyspnea
Restlessness Headache
Tachycardia
Immediate management of Category 2—Moderately severe reactions:
 Stop the transfusion and keep IV line open with normal saline in another site.
 Return the blood unit with transfusion administration set, freshly collected urine and new
blood samples (1 clotted and 1 anticoagulated), drawn from a vein opposite to transfusion
site, to the blood transfusion centre for laboratory investigations.
 Administer antihistamine IM & oral or rectal antipyretic.
 Avoid aspirin in thrombocytopenic patients.
 Give IV (intravenous) corticosteroids and bronchodilators if there are anaphylactoid features
(e.g. bronchospasm, stridor).
 If clinical improvement occurs, restart transfusion slowly with new blood unit and observe
carefully.
 If no clinical improvement within 15 minutes or if signs and symptoms worsen, treat as
Category 3.
 Collect urine for next 24 hrs for evidence of hemolysis & send for laboratory investigations.
If available, a leucocyte reduction filter (WBC filter) may be used in repeated transfusion.

Table 5: Category 3—Life‐threatening reactions:

Signs Symptoms Possible cause
Rigor Anxiety Acute intravascular hemolysis (mis-
Fever Chest pain matched blood transfusion)
Restlessness Pain along Bacterial contamination
Hypotension (fall of 20% in SBP) transfusion line Septic shock
Tachycardia (rise of 20% in HR) SOB Fluid overload
Hemoglobinuria (Hb in urine) Loin/back pain Anaphylaxis
Unexplained bleeding (DIC) Headache Transfusion related acute lung injury
Dyspnea
Immediate management of Category 3—Life‐threatening reactions:
 Stop the transfusion and keep IV line open with normal saline in another site.
 Infuse normal saline to maintain systolic BP (SBP).
 Maintain airway and give high flow oxygen by mask.
 Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by slow IM injection.
 Give IV corticosteroids and bronchodilators if there are anaphylactoid features.
 Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
 Check a fresh urine specimen visually for signs of hemoglobinuria.
 Notify the superior or senior doctor attending the patient, and the blood centre immediately.
 Send blood unit with transfusion set, fresh urine sample and new blood samples (1 clotted
and 1 anti-coagulated), drawn from a vein opposite the infusion site, with appropriate request
form to the blood transfusion centre for investigation.
 Start a 24‐hour urine collection and record all intake and output. Maintain fluid balance chart.
 Assess for bleeding from puncture sites or wounds. If there is clinical or laboratory evidence
of DIC, give platelets (adult: 4‐6 units) and either cryoprecipitate (adult: 12 units) or FFP
(adult: 3 units).
 Reassess. If hypotensive:
o Give further saline.
o Give inotrope, if available.
 If urine output falls or there is lab evidence of acute renal failure (rising K+, urea, creatinine):
o Maintain fluid balance accurately.
o Give further diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
o Consider dopamine infusion, if available.
o Seek expert help: the patient may need renal dialysis.
 If bacteremia is suspected (rigor, fever, collapse, no evidence of a hemolytic reaction), start a
broad‐spectrum antibiotic IV.
7.2 Investigating acute transfusion reactions
 Immediately report all acute transfusion reactions, with exception of mild hypersensitivity
(Category 1) to doctor responsible for patient and to blood transfusion centre that supplied
the blood. If a severe life‐threatening reaction is suspected, seek help immediately from the
blood transfusion expert/anesthetist/emergency team/whoever is available & skilled to assist.
 Record the following information on the patient’s notes:
o Type of transfusion reaction.
o Time lapse between start of transfusion and when reaction occurred.
o Volume, type and bag number of blood products transfused.
 Immediately take post‐transfusion blood samples (1 clotted and 1 anti‐coagulated) from vein
opposite the transfusion site and forward to blood centre for investigation of the following:
o Repeat ABO and RhD group.
o Repeat antibody screen and cross match.
o Full blood count.
o Coagulation screen.
o Direct antiglobulin test.
o Urea and creatinine.
o Electrolytes.
 Also return the following to the blood centre:
o Blood bag and transfusion set containing RBC and plasma residues from transfused unit.
o Blood culture in a special blood culture bottle.
o First specimen of the patient’s urine following the reaction.
o Completed transfusion reaction report form.
 After initial investigation of the reaction, send patient’s 24‐hour urine sample to the blood
transfusion centre for laboratory investigation.
 Record the results of the investigations for future follow‐up, if required.

7.3 Hemolytic transfusion reaction

An acute hemolytic transfusion reaction is the result of a mismatched blood transfusion, and
causes acute intravascular hemolysis.
 Acute intravascular hemolytic reaction is caused by transfusion of incompatible RBCs, i.e.
mismatched blood. Antibodies in patient’s plasma hemolyze incompatible RBCs transfused.
 Even a small volume (5‐10 mL) of incompatible blood can cause a severe reaction and larger
volume increases the risk.
 Most common cause of reaction is ABO incompatible transfusion, almost always arises from:
o Errors in the blood request form.
o Taking blood from the wrong patient into a pre‐labeled sample tube.
o Incorrect labeling of the blood sample tube sent to the blood transfusion centre.
o Inadequate checking of the blood label against the patient’s identity.
 Antibodies in the patient’s plasma against other red cell antigens present on transfused blood,
such as those of Kidd, Kell or Duffy blood group systems, can also cause acute hemolysis.
 In conscious patient, signs and symptoms usually appear within minutes of commencing
transfusion, sometimes when < 10 mL blood has been given. In unconscious or anesthetized
patient, hypotension and uncontrollable bleeding, from transfusion site, may be only sign of
an incompatible transfusion.
 It is therefore essential to monitor the patient from the commencement of transfusion up to its
completion.
Prevention:
 Correctly label blood sample and request form.
 Place the patient’s blood sample in the correct sample tube.
 Always check blood unit against the identity of the patient at the bedside before transfusion.

7.4 Bacterial contamination and septic shock

 Bacterial contamination affects up to 0.4% of red cells and 1‐2% of platelet concentrates.
 Blood may become contaminated by:
o Bacteria from donor’s skin entering blood unit during collection (usually staphylococci).
o Bacteremia present in the blood of the donor during collection (e.g. Yersinia).
o Improper handling during blood processing.
o Defect or damage to the blood bag.
o Thawing FFP or cryoprecipitate in a water‐bath (often contaminated).
 Some contaminants, particularly Pseudomonas species, grow at +2°C to +6°C and can
survive or multiply in refrigerated red cell units. Staphylococci grow in warmer conditions
and are able to proliferate in PCs which are stored at +20°C to +24°C.
 Signs usually appear rapidly after starting infusion, but may be delayed for a few hours.
 A severe reaction may be characterized by sudden onset of high fever, rigors & hypotension.
 Urgent supportive care and high‐dose intravenous antibiotics are required.

7.5 Transfusion associated circulatory overload

 Transfusion associated circulatory overload (TACO), i.e. fluid overload, can result in heart
failure and pulmonary edema.
 May occur when:
o Too much fluid is transfused.
o The transfusion is given too rapidly.
o Renal function is impaired.
 Fluid overload is particularly likely to happen in patients with:
o Chronic severe anemia.
o Underlying cardiovascular disease.

7.6 Anaphylactic reaction

 This is a rare complication of transfusion of blood components or plasma derivatives.
 The risk is increased by rapid infusion, typically when fresh frozen plasma is used.
 IgA deficiency in the recipient is a rare cause of very severe anaphylaxis. This can be caused
by any blood product since most contain traces of IgA.
 Cytokines in plasma may occasionally cause broncho‐constriction and vaso‐constriction in
recipients.
 Occurs within minutes of starting the transfusion and is characterized by:
o Cardiovascular collapse.
o Respiratory distress.
o No fever.
 Anaphylaxis is likely to be fatal if it is not managed rapidly and aggressively.
7.7 Transfusion related acute lung injury (TRALI)
 TRALI is usually caused by donor plasma that contains antibodies against patient’s WBCs.
 Rapid failure of pulmonary function usually presents within 1‐4 hours of starting transfusion,
with diffuse opacity on the chest X‐ray.
 No specific therapy. Intensive respiratory and general support in an ICU is required.

7.8 Delayed complications of transfusion

7.8.1 Delayed hemolytic transfusion reaction: Signs appear 5‐10 days after transfusion:
 Fever.
 Anemia.
 Jaundice.
 Occasionally hemoglobinuria.
Severe, life‐threatening delayed hemolytic transfusion reactions with shock, renal failure & DIC
are rare.

7.8.2 Post‐transfusion purpura

 This is a rare but potentially fatal complication of transfusion of red cells or platelet
concentrates, caused by antibodies directed against platelet‐specific antigens in the recipient.
 Most commonly seen in multigravida female patients.
 Signs and symptoms:
o Signs of bleeding.
o Acute, severe thrombocytopenia 5‐10 days after transfusion, defined as a platelet count of
< 100  109/L.
 Management: Management becomes clinically important at a platelet count of 50  109/L,
with a danger of hidden (occult) bleeding at 20  109/L.
o Give high dose corticosteroids.
o Give high dose IV immunoglobulin, 2 g/kg or 0.4 g/kg for 5 days.
o Plasma exchange.
o Monitor the patient’s platelet count: normal range is 150  109/L to 440  109/L.
o If available, give platelet concentrates that are negative for the platelet‐specific antigen
against which the antibodies are directed.
o Unmatched platelet transfusion is generally ineffective.
o Recovery of platelet count after 2‐4 weeks is usual.

7.8.3 Transfusion associated graft‐versus‐host disease (TA‐GVHD)

 Unlike transplant associated GVHD, TA‐GVHD it is usually a fatal condition.
 Occurs in patients such as:
o Immuno‐deficient recipients of bone marrow transplants.
o Immuno‐competent patients transfused with blood from individuals with whom they have
a compatible HLA tissue type, usually blood relatives particularly 1st degree.
 Signs and symptoms: Typically occur 10‐12 days after transfusion and are characterized by:
o Fever.
o Skin rash and desquamation.
o Diarrhea.
o Hepatitis.
o Pancytopenia.
 Management: Treatment is supportive; there is no specific therapy.
 Prevention: Do not use 1st degree relatives as donors, unless gamma irradiation of cellular
blood components is carried out to prevent the proliferation of transfused lymphocytes.

7.8.4 Transfusion transmitted infections: Following infections may be transmitted:

 HIV, Hepatitis B and C, syphilis (Treponema pallidum), malaria.
 Cytomegalovirus (CMV).
 Other TTIs include human parvovirus B19, brucellosis, Epstein‐Barr virus, toxoplasmosis,
Chagas disease, infectious mononucleosis and Lyme’s disease.
Since a delayed transfusion reaction may occur days, weeks or months after transfusion, the
association with transfusion may easily be overlooked. It is essential to record all transfusions
accurately in the patient’s case notes and to consider transfusion in the differential diagnosis.
8 Massive blood transfusion
Massive blood transfusion may be defined as replacement of one blood volume (equivalent to 10
units of blood) in any 24 hr period, or half of blood volume (5 units of blood) in any four hour
period in an adult.
 Replacement of a blood volume equivalent within 24 hours.
 >10 units within 24 hours.
 Transfusion >4 units in 1 hour.
 Replacement of 50% of blood volume in 3‐4 hours.
 A rate of loss >150 ml/hour.

Massive transfusion occurs in settings such as severe trauma, ruptured aortic aneurysm (AA),
surgery and obstetric complications. Goals to management of massive transfusion include early
recognition of blood loss, maintenance of tissue perfusion, oxygenation by restoration of blood
volume and hemoglobin, and cessation of bleeding by several means including early surgical or
radiological intervention, and judicious use of blood component therapy to correct coagulopathy.
 Plasma undergoes progressive loss of coagulation factors during storage, particularly 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. Massive or large volume transfusions can result in disorders
of coagulation.

Massive Transfusion Protocol: A massive transfusion protocol (MTP) should be used in

critically bleeding patients anticipated to require massive transfusion. The parameters in Table 6
below should be measured early and frequently (every 30‐60 minutes, or after transfusion of
blood component).
Table 6: Parameters in massive transfusion – investigation and monitoring
Parameter Values for which to aim
Temperature >35°C
Acid‐base status pH >7.2, base excess < –6, lactate <4 mmol/L
Ionized calcium >1.1 mmol/L
Hemoglobin Should not be used alone as a transfusion trigger; and, should be
interpreted in context with hemodynamic status, organ & tissue perfusion
Platelets ≥ 50  109/L
PT/APTT ≥ 1.5 of normal
Fibrinogen ≥ 1.0 g/L
Mortality is high in massive transfusion and its etiology is multifactorial, which includes
hypotension, acidosis, coagulopathy, shock and the underlying condition of the patient. Lethal
triad i.e. patients with acidosis, hypothermia, and coagulopathy have the highest mortality rate.
It is often the underlying cause and consequences of major hemorrhage that result in
complications, rather than the transfusion itself. However, administering large volumes of blood
and intravenous fluids may itself give rise to the following complications.
 Acidosis: Acidosis in a patient receiving a large volume transfusion is more likely to be the
result of inadequate treatment of hypovolemia than due to effects of transfusion. Under the
normal circumstances, body can readily neutralize this acid load from transfusion. Routine
use of HCO3- or other alkalizing agents, based on number of units transfused, is unnecessary.
 Hyperkalemia: Storage of blood results in a small increase in extracellular K+ concen-
tration, which will increase the longer it is stored. This rise is rarely of clinical significance,
other than in neonatal exchange transfusions. Fresh blood (up to 7 days old) should be
requested from the blood center.
 Citrate toxicity and hypocalcemia: Citrate toxicity is rare, but is most likely to occur
during the course of a large volume transfusion of whole blood. Hypocalcemia, particularly
in combination with hypothermia and acidosis, can cause reduction in cardiac output,
bradycardia and other dysrhythmias. Citrate is usually rapidly metabolized to HCO3-. It is
therefore unnecessary to attempt to neutralize the acid load of transfusion. There is very little
citrate in red cell concentrates.
Management:
 If there is prolongation of PT, give ABO compatible fresh frozen plasma in a dose of 15
mL/kg.
 If the APTT is also prolonged, Factor VIII/fibrinogen concentrate is recommended in
addition to FFP. If none is available, give 10‐15 units of ABO compatible cryoprecipitate,
which contains Factor VIII and fibrinogen.
 Give PCs only when:
o Patient shows clinical signs of microvascular bleeding i.e. bleeding and oozing from
mucous membranes, wounds, raw surfaces and catheter sites.
o Patient’s platelet count falls below 50  109/L.
 Give sufficient PCs to stop microvascular bleeding and maintain an adequate platelet
count.
 Consider PC transfusion in cases where platelet count falls < 20109/L, even if there is no
clinical evidence of bleeding, because there is a danger of occult bleeding, such as into
brain tissue.
Prophylactic use of PCs in patients receiving large volume blood transfusions is not
recommended.
9 Transfusion in Pediatrics
Pediatric anemia is defined as a reduction of Hb concentration or red cell blood volume below
the normal values for healthy children. Normal Hb/Hct values differ according to the age of the
child.

Indications for Transfusion:

 Hb ≤ 4 g/dL or Hct 12%.
 Hb 4‐6 g/dL (or Hct 13‐18%) if any of following clinical features are present:
o Clinical features of hypoxia.
o Acidosis (usually causes dyspnea).
o Impaired consciousness.
o Hyper‐parasitemia (>20% malarial parasites).

Transfusion of Neonates and Infants: Following recommendations apply to transfusion of

children in first four months of life:
 Pre‐transfusion testing:
o Maternal samples:
 ABO and RhD group.
 Antibody screen (5 mL clotted blood).
o Infant samples:
 ABO and RhD group.
 Direct antiglobulin test (DAT).
 Antibody screen if maternal sample unavailable (1‐2 mL clotted blood).
 If maternal antibody screen is negative and infant’s RBCs are DAT negative, cross matching
is unnecessary and blood of baby’s group can be issued. Alloantibodies are rare in first four
months of life and are related to repeated massive transfusions and to use of fresh blood.
 If maternal antibody screen and/or the neonatal DAT are positive, serological investigation
and full compatibility testing will be necessary.
 After first four months of life, cross matching procedures should conform to the requirements
for older children/adults.

9.1 Top‐up transfusion

Top‐up transfusions are carried out in order to raise Hb concentration in symptomatic chronic
anemia, often due to blood sampling in sick premature infants.
 Limit donor exposure whenever possible: if repeated transfusions are likely then notify the
blood transfusion department so that satellite bags (40 mL each) can be arranged.
 PRBC (Hct 0.55‐0.75) should be used for top‐up transfusions. Red cells in optimal additive
solutions, e.g. SAG‐M/CPD blood can be safely used for top‐up transfusion in this age group.
 Complete transfusion within 4 hours. Transfusion rates of 5 mL/kg/hour are safe: increase
rate if active hemorrhage and reduce if cardiac failure exists.
 Due to the small volume of blood to be transfused, it is acceptable to flush the giving set with
an appropriate fluid, e.g. isotonic (normal) saline to extract the full volume of red cells.

9.2 Exchange transfusion

The main indication for neonatal exchange transfusion is to prevent neurological complications
(kernicterus) caused by a rapidly‐rising unconjugated bilirubin concentration.
Option for blood group is as follows:
 Use group O blood that does not carry the antigen to which the maternal antibody is directed.
 For HDN due to anti‐D use group O RhD negative blood.
 Use blood of the ABO group of the neonate or use an alternative group which is compatible
with maternal ABO antibodies, and also ABO compatible with the infant. Otherwise, use
designated group O Rh compatible units.
 Use blood compatible with any maternal irregular antibodies.
 Storage age of blood should be within five days of collection.

When carrying out an exchange transfusion use whole blood for the first exchange followed by
plasma‐reduced blood (Hct 0.55‐0.60) for the second exchange. This is the only indication for
the use of whole blood.
 Use a blood warmer. Only approved and regularly monitored blood warming equipment
should be used: fatal transfusion reactions have followed the use of inappropriate blood
warming procedures.

Transfusion Procedure:
 If transfusion is needed, give sufficient blood to make the child clinically stable.
 5 mL/kg of red cells or 10 mL/kg whole blood are usually sufficient to relieve acute shortage
of oxygen‐carrying capacity. This will increase Hb concentration by approximately 2‐3 g/dL
unless there is continued bleeding or hemolysis.
 A red cell transfusion is preferable to whole blood for a patient at risk of circulatory
overload, which may precipitate or worsen cardiac failure. 5 mL/kg of red cells gives the
same oxygencarrying capacity as 10 mL/kg of whole blood and contains less plasma protein
and fluid to overload the circulation.
 Where possible, use a pediatric blood pack and a device to control the rate and volume of
transfusion.
 Although rapid fluid infusion increases the risk of volume overload and cardiac failure, give
the first 5 mL/kg of red cells to relieve the acute signs of tissue hypoxia. Subsequent
transfusion should be given slowly: e.g. 5 mL/kg of red cells over 1 hour.
 Give frusemide 1 mg/kg by mouth or 0.5 mg/kg by slow IV injection to a maximum dose of
20 mg/kg if the patient is likely to develop cardiac failure and pulmonary edema. Do not
inject it into the blood pack.
 Monitor during transfusion for signs of:
o Cardiac failure.
o Fever.
o Respiratory distress.
o Tachypnea.
o Hypotension.
o Acute transfusion reaction.
o Shock.
o Hemolysis (jaundice, hepatosplenomegaly).
o Bleeding due to DIC.
 Re‐evaluate the patient’s Hb or Hct and clinical condition after transfusion.
 If the patient is still anemic with clinical signs of hypoxia or a critically low Hb level, give a
second transfusion of 5–10 mL/kg of red cells or 10–15 mL/kg of whole blood.
 Continue treatment of anemia, such as with iron, to help hematological recovery.

If exchange transfusion is needed:

 An exchange transfusion of about two times the neonate’s blood volume (about 170 mL/kg)
is most effective to reduce bilirubin and restore Hb level; this can usually be carried out with
one unit of whole blood.
 A unit of whole blood will normally have an Hct of 37–45%, which is more than adequate
for neonatal needs.
 When exchange transfusion is performed to treat hemolytic disease of the newborn (HDN),
the transfused red cells must be compatible with the mother’s serum since the hemolysis is
caused by maternal IgG antibodies that cross the placenta and destroy the fetal red cells.
 The blood should therefore be cross matched against mother’s serum using the antiglobulin
method that detects IgG antibodies.

9.3 Hemolytic Disease of the Newborn

HDN is caused by antibodies that are produced by the mother. These antibodies are IgG and can
cross the placenta and destroy the fetal red cells. The mother may develop these antibodies:
 If fetal RBCs cross the placenta (feto‐maternal haemorrhage) during pregnancy or delivery.
 As a result of a previous red cell transfusion.
HDN due to ABO incompatibility between mother and infant does not affect the fetus in utero,
but is an important cause of neonatal jaundice.
HDN due to RhD incompatibility is an important cause of severe fetal anemia in countries where
a significant proportion of population is RhD negative. RhD negative mothers develop antibodies
to an RhD positive fetus, especially when mother and infant are of the same or compatible ABO
blood type. Fetal RBCs are hemolyzed, causing severe anemia.
In the most severe cases of HDN:
 The fetus may die in utero.
 The fetus may be born with severe anemia that requires replacement of red cells by exchange
transfusion.
 There may also be severe neurological damage after birth as a result of a high bilirubin level
unless this is corrected by exchange transfusion.
HDN due to other blood group antibodies can also occur, in particular anti‐c (also within the Rh
blood group system) and anti‐Kell.
Screening in pregnancy:
 ABO and RhD group of all pregnant women should be determined when they first attend a
clinic for antenatal care. Mother’s blood should also be tested for any IgG red cell antibodies
that can cause HDN.
 If no antibodies are detected at the first antenatal visit, the pregnant woman should have a
further antibody check at 28‐30 weeks gestation.
 If antibodies are detected at the first antenatal visit, the levels should be monitored frequently
throughout the pregnancy in case they increase. Rising levels are likely to be indicative of
HDN developing in the fetus.
Anti‐RhD immunoglobulin: Anti‐RhD immunoglobulin prevents sensitization and production
of antibodies in an unsensitised RhD negative mother if RhD positive red cells gain entry into
her circulation, either during pregnancy or during delivery.

9.4 ABO hemolytic disease of the newborn

 Diagnosis of ABO HDN is usually made in infants born at term who are not severely anemic,
but who develop jaundice during the first 24 hours of life.
 ABO incompatibility does not present in utero and does not cause hydrops.
 Neonate should receive phototherapy and supportive treatment; treatment should be initiated
promptly as jaundice can become severe enough to lead to kernicterus.
 Blood units for exchange transfusion should be group O with low‐titre anti‐A and anti‐B.
 A two‐volume exchange (approximately 170 mL/kg) is most effective in removing bilirubin.
 If bilirubin rises again to dangerous levels, a further two‐volume exchange should be
performed.

9.5 Transfusion of Platelets and FFP in Pediatric Patients

 Platelet transfusion:
Platelet transfusions are indicated in neonates and young infants with a count below 50 
109/L who are experiencing bleeding.
 Dose: 5‐10 mL PC/kg body weight will increase count by 50  109/L to 100  109/L.
 Transfusion of FFP:
 Dose: 10‐15 mL/kg in coagulopathy condition.

Pediatric blood bags are available for blood transfusion (BT) of the infant patient. It should be
remembered that once a blood bag unit has been opened for transfusion it should be completed.
Partial transfusion of a single bag over successive days is not permitted due to risk of infection.
10 Blood Transfusion Services in Bangladesh
To improve the safety of blood transfusion, from the year 2000 the government developed
facilities, in medical college hospitals, institutes, combined military hospitals, specialized
hospitals, district hospitals and at Upazila health complex. Strengthening of blood transfusion
centers started under the Safe Blood Transfusion Program of the Ministry of Health and Family
Welfare (MOHFW). A legislative framework, the ‘Safe Blood Transfusion Act, 2002’ was
enacted by the Government. Blood transfusion centers supply blood after testing for markers to
five TTIs i.e. HIV, Hepatitis B, Hepatitis C, syphilis and malaria, the requirement of which has
been made mandatory in accordance with the ‘Safe Blood Transfusion Law’ in the country.
 National Safe Blood Transfusion Council: This is a policy making forum for blood
transfusion services under the MOHFW for developing the policy as per directives of the
Safe Blood Law/Act for improvement of blood transfusion services. The honorable Health
Minister, by position, is the President and Director General of Health Services and is the
Member Secretary of the Council. Directors of institutes, and the head of the department of
blood transfusion, are members of this council.
 National Safe Blood Transfusion Expert Committee: National Safe Blood Transfusion
Expert Committee is an implementing body for policy and decision making by National Safe
Blood Transfusion Council, headed by Director General DGHS under MOHFW. It consists
of transfusion specialists as members, and Director General is the president of the committee.
 Local Hospital Transfusion Committee: Each hospital has a local blood transfusion
committee which is constituted with participation of head of the department of all disciplines
in the hospital.
 Statutory Regulation Order: The government has formulated rules for the management of
blood centers which is known as SRO‐145.

Figures 4, 5 and 6 on the following pages, provide examples of a crossmatch report form, a form
for making transfusion notes and a form for making notes on the management of adverse
transfusion reaction, respectively.
Figure 4: Cross match report form

National Blood Transfusion Services

Department of Transfusion Medicine (Blood Transfusion)
_______________________________________Hospital

COMPATIBILITY/CROSS MATCH REPORT

Sl. No.: ………… Date: ……………
 Lab./Ref. No.: …………
 Patient's Name: ……………………… Blood Group: …………
Age: …………… Sex: ……… M/F Race: ………………
 Cabin/Ward No.: …………… Bed No.: ……… Unit: ………
 Hospital/Clinic Reg. No.: …………… Donor Bag No.: ………
Blood Group: ………………… Compatible

Medical Technologist Duty Doctor

Received by:
………………………………………………………………………
National Blood Transfusion Services
Department of Transfusion Medicine (Blood Transfusion)
_______________________________________Hospital

COMPATIBILITY/CROSS MATCH REPORT

Sl. No.: ………… Date: …………
 Lab./Ref. No.: ……………
 Patient’s Name: ……………………… Age: ……… Sex: M/F
 Blood Group of Patient: ABO ……… Rhesus ………
 Donor Blood Group: ABO ……… Rhesus ………
Donor Blood Sample (Bag No. …………) is found compatible with
Patient’s Blood Sample (Lab./Ref. No. ………)
Supplied on ……………… at ………………
 Blood sample of the supplied bag was tested for
………………………………………………………
__________________ _______________
Medical Technologist Duty Doctor
১। এ রিপ োপটে ি তথ্যোরিি সোপথ্ রিসঞ্চোলপেি পূ ব অবশ্যই
ে বযোপেি েোপে ললখো তথ্যোরি রিরলপে রেে।
২। কৃত্রিি িক্ত বযোে েিি কিো উরিত েে।
৩। িক্ত বযোপেি িপযয অথ্বো লসপট লকোে িকি ঔষয লিশ্োপেো সম্পূর্ রেরষদ্ধ।
ে
৪। লিফ্রজোপিটি হপত লবি কোিোি ৩০ রিরেপটি িপযয রিসঞ্চোলে কিো উরিত।
Figure 5: Transfusion Notes

Patient ID Date
Patient Name Age Sex
Diagnosis Ward Bed

Blood Group Pre‐transfusion Hb g/dL Date

Source of Blood Bag number

Collection Date Type of component
Amount of blood Cross match & Screening Lab ID

Transfusion start time

Parameter Pretransfusion 15 min 30 min 1 hour 2 hours 3 hours 4 hours

Pulse
BP
Temperature
Respiration
Color of urine
Drop rate/min

Time transfusion completed: 

Completion of Transfusion was successful without any adverse reaction
transfusion note Transfusion was deferred due to adverse reaction of severe category
(checkanswer) Transfusion was completed e management of febrile/allergic reaction

Signature of doctor
Figure 6: Management of adverse transfusion reaction: physician’s notes
Chief Complaint/Concern: Treatment:

On Examination:
Pulse
BP
Respiratory Rate
Sign of bleeding

Investigation:
Blood samples: blood bag, patient
Urine, culture, electrolytes
BT, CT, APTT, bilirubin, DAT

Report of blood transfusion centre:

Instruction of Experts: (transfusion specialist/

anesthetic/ departmental head)
Signature of Doctor