Introduction :

Transfusion is extremely safe today, however the general perception that transfusions are unsafe persists thanks largely due to the HIV pandemic and risk of post transfusion hepatitis. Today very often it is said, " The best blood is the one that you have not received." Preventable death due to wrong identification of blood still occurs and is largely occur due to human error. Ignorance among clinicians about how to transfuse blood adds further to these preventable deaths.

As a clinician, one will have to be aware of:

• Indications for blood transfusion
• Alternatives to blood transfusion
• Administration of blood
• Transfusion reactions
• Informed consent for blood transfusion
• Component therapy
• Do's & Don'ts of blood transfusion
  

Ordering Blood:

Safe transfusion practice begins with correct identification of the intended recipient. Blood samples of the recipient should be identified and labeled properly. Test recipient's blood for ABO Group, Rh type, Coomb's & crossmatch.

STEPS AT THE TIME OF ISSUE OF BLOOD:

• Identify intended recipient
• Compare ABO group and Rh type of the primary label and transfusion form
• Inspect color & expiry date of blood bag. Blood bag with clots, pinkish discoloration of plasma, purple discoloration should not be issued.
• Record of issuing person, Date, Time and person to whom issued is to be maintained so that in case of an adverse reaction the person can be contacted to help identify the cause of transfusion reaction.
  

ISSUING OF BLOOD AND BLOOD COMPONENT:

• Administer blood within half an hour of issue from blood bank.
• ½ Hour time limit is empirical and is the time taken for blood bag to reach 10 degree Celsius temp.
• No blood bank will accept blood back if it has reached 10-degree temp and it has to be discarded.
• Non-medical reasons for delay in starting blood transfusion can be avoided by properly educating transfusionist.
• Open system of blood e.g. saline washed RBC should be used within 24 hr.
• Blood components like cryoprecipitate & FFP should be used with in 6 hrs of issue.
• In case of delay in initiating blood transfusion, return the blood bag to blood bank immediately.
• Don't store blood or blood component in unmonitored nursing station refrigerator as storage temp for blood of 0 to 4 degree Celsius cannot be assured and gives a false sense of security. This is a common practice in small nursing homes and ICCU and surgical theaters of most institutions.
• Platelet bags should not be stored in a refrigerator, it should be maintained at 22 to 24 degree Celsius on a constant agitator.
  

STEPS AT THE TIME OF INFUSION:

• Check all identifying information.
• Identity the recipient on transfusion form, compatibility label, ABO group, Rh type, Donor unit identification no. & Expiry date.
• Transfusionist must start transfusion only on physician's "written orders".
  

STARTING THE TRANSFUSION:

• Record Date and Time of beginning and termination of blood transfusion.
• Record amount of blood transfused.
• Patient's record should be checked once again to verify correct identification.
• Record patient's vital parameters prior to initiation of blood and then every 15 minutes, as changes in vital parameters are the first change to occur in case of a transfusion reaction.
  

CARE DURING TRANSFUSION:

• First half an hour is crucial.
• Risk of catastrophic event like ABO hemolytic reaction and anaphylactic reaction is maximum in the first ½ hr.
• Risk declines sharply after ½ hr.
• Record vital signs every 15 minutes.
• Increase rate of infusion to required rate.
• Observe through out transfusion.
  

RATE OF INFUSION OF BLOOD:

• First ½ hr is slow.
• If no reaction, increase the rate depending on recipient's haemodynamic status.
  
  • If haemodynamically stable, transfuse over 2 hours.
  • If haemodynamically unstable, transfuse over 4 hours.
• This time limit is empirical based on the time it takes the blood bag to reach room temperature. Since blood is an excellent culture media, keeping the blood bag at room temperature for longer duration could result in bacterial overgrowth.
• In case, medical condition of recipient demands transfusion over a longer period ask for split units of blood from blood bank and give each over 4 hours.
• Rapid infusion may be necessary in certain clinical setting, then use mechanical devices for rapid infusion of blood. Blood pressure cuff is unsuitable for providing external pressure.
  

DISCONTINUING BLOOD TRANSFUSION:

• Record time, Volume and type of component given.
• Check patient's condition and vital parameters.
• Return transfusion form to transfusion service i.e. blood bank.
• Observe patient for one hour.
• Do post transfusion monitoring: HCT, platelet counts, coagulation factors. (delayed transfusion reaction may be recognized if there is inappropriate rise in HCT.) Monitor for PTH ( post transfusion hepatitis )