Blood Transfusion

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Blood components 

A single donation of blood can be separated into several blood components. Currently in Tanzania  the following blood components are available for transfusion: packed red blood cells, Fresh Frozen  Plasma, single unit platelet (plasma rich) and whole blood units. 

  1. Whole blood
    • One  unit contains 450mls of blood. It is poor in  platelets and  clotting  factors and  can  be  stored for 35days at 2-6°C.
    • Indications:  Exchange  transfusion,  open  heart  surgery,  and  in  the  absence  of  PRBCs  in patients with acute blood loss and hypovolaemia.
  2. Packed red blood cells (PRBCs)
    • It can be stored for 35days at 2-6°C. One unit increases haemoglobin (Hb) level by approximately  1g/dl in adult, whereas in children, a dose of 10-15mls/kg will increase the Hb by about 3g/dl. 
    • Indications: acute blood loss, exchange transfusion, cardiac patients with Hb level <8g/dl, chronic  symptomatic anaemia with Hb <5g/dl, preoperative patients with Hb level <8g/dl, pre-radiotherapy  patients  with  Hb  level  <10g/dl,  pre  and  post  chemotherapy  patients  with  Hb  <9g/dl,  and  patients  admitted to ICU with Hb <7g/dl. 
  3. Platelets
    • A  single  random  donor  platelet  (RDP)  from  one  whole  blood  unit  and  contains  about  5.5X109/L platelets in 50ml unit. It is stored at room temperature (20-24°C) and has a life span of 5days. Dosage: 50mls per 10kg i.e 5-6 RDP units in adults. In infants < 10kg, the dose is 5mls/kg, one adult therapeutic dose increases platelet counts by approximately 20-40 X109/L.
    • Indications 
      • Therapeautic:  thrombocytopenia  of  platelet  counts<  50X109/L  with  clinical  evidence  of bleeding.
      • Prophylactic in patients with platelet counts of:  <10 X109/L, <20X109/L with additional risk factor  of  bleeding,  <50X109/L  and  planned  for  minor  surgery,  <100X109/L  with  multiple injuries,  or  microvascular  bleeding,  or  planned  for  major  surgery.  Also,  in  massive transfusion to maintain a platelet count of >50X109/L.
    • Contraindications:  Absolutely  contraindicated  in  heparin  induced  thrombotic  thrombocytopenia  (HITT)  and  thrombotic  thrombocytopenic  purpura  (TTP).  Relatively  contraindicated  in  idiopathic  thrombocytopenia (ITP) unless a life-threatening bleeding is anticipated. 
  4. Fresh frozen plasma (FFP)
    • FFP prepared from one unit of whole blood contains about 200-300mls of plasma. It is stored at - 18°C  and  contains  all  clotting  factors  in  physiological  levels  except  factors  V  and  VIII  which  are present in slightly reduced amount. It has a life span of 12 months. Thaw FFP in water bath at 30- 37°C and transfuse within 30 minutes after thawing. It expires 24 hours after thawing.
    • Dosage: 10-20ml/kg, approximately 4-6 units for adult, this will raise a minimum of 30% of plasma  clotting factors. 
    • Indications: haemophilia if factor concentrates not available, patients with significant coagulopathy  eg DIC, Vitamin K deficiency and massive transfusion, thrombotic thrombocytopenic purpura (TTP)  or haemolytic uremic syndrome (HUS) as top up or exchange plasma transfusion, scoline apnoea,  haemorrhagic disease of the newborn. 

Investigations 

Before transfusion:FBC, ABO and Rh-blood grouping and crossmatch (cross matching not needed for platelets and FFP transfusion), If  transfusion  adverse  reaction  occurs:  Assess  for  haemolysis  (FBC,  peripheral  smear, direct  antiglobulin  test,  serum  bilirubin,  serum  LDH),  re-grouping  and  crossmatch,  other tests depending on the type of transfusion reaction.

Types of blood transfusion 

  • Acute simple/episodic transfusion
    • Used in management of symptomatic patients with anaemia or bleeding tendencies 
  • Chronic/top up transfusion
    • Used as prophylactic to prevent complications, eg. In patients with sickle cell anaemia (SCA) 
  • Exchange blood transfusion
    • Used in management of severe neonatal jaundice, in patients with SCA with acute chest syndrome, suspected acute stroke or transient ischaemic attack. 
  • Massive blood transfusion
    • Transfusion of blood volumeto patient equivalent to his/her total blood volume in less than 24 hours,  or 10 units or more in 24 hours. Administer in parallel a 1:1:1 ratio of 6 Units of RBCs, 6 Units of FFP  and 6 Units of Platelets. The target is to achieve 1:1:1 ratio over 6 hours. Aim the PT, PTT <1.5x  control  mean,  fibrinogen  >1  g/L,  target  platelet  >  100x109/L  if  pts  has  CNS  trauma,  eye  and  >  50x109/L for other type of injuries.  

Plasma Derived Medicinal Products (PDMPs) available from commercial outlets 

  • Haemosolvate factors VIII and IX used in management of haemophilia
  • Immunoglobulins used in immune-mediated conditions
  • Albumin used in management of hypovolaemia, hypoalbuminaemia and in therapeautic plasma exchange.

Therapeautic phlebotomy 

Indications: Polycythemia, and in hereditary iron overload. 

Table: 3.4 Adverse effects of blood transfusion 

Reaction Transfusion Management
Acute immunologic reactions Acute haemolytic transfusion reaction
  • Stop transfusion, supportive care to maintain hemodynamics. 
  • Regroup and crossmatch donor and recipient’s samples. 
  • Assess for haemolysis. 
Allergic reactions Stop transfusion, administer antihistamine eg 
Chlorphenamine 4mg PO as needed +/- steroid eg Hydrocortisone 100mg IV stat, resume transfusion if symptoms subside. If anaphylactic reaction, add vassopressors eg epinephrine and supportive care. 
Febrile non-haemolytic transfusion reaction

Stop transfusion, administer antipyretics A: Paracetamol 1g PO as needed+/- steroid eg Hydrocortisone 100mg IV stat, resume transfusion if symptoms subside.
Transfusion-related acute lung injury (TRALI) Stop transfusion, oxygen supplementation and mechanical ventilation if required
Transfusion associated graft-versus-host disease (TA-GVHD) Supportive care 
Delayed immunologic reactions

Delayed hemolytic transfusion reaction 

Symptomatic treatment, request extended cross match for additional transfusions. 

Post-transfusion purpura 

Self limiting,

S: IV immunoglobulin 0.4g/kg/day IV for 5days or plasma exchange may be needed in severe cases. 
Acute non-immunologic reactions

Transfusion-related circulatory overload (TACO) 

 Stop transfusion, administer diuretics, manage as cardiac failure. See details under cardiovascular diseases chapter. 
Bacterial Contamination Stop transfusion, antibiotics and supportive care
Delayed non-immunologic reactions  Infectious disease transmission Manage the infection accordingly eg HIV, Hepatitis B & C. see details under respective chapters 
Iron overload Iron chelation with deferroxamine 

Blood transfusion in Jehovah’s witness 

  • Blood transfusion is a medical treatment, and therefore patients have the right to refuse treatment.
  • Inform the patient of the benefits and risks of transfusion.
  • Enable the patients to understand the consequences of not receiving blood.
  • Inform the patients of any alternatives to transfusion available eg autologous transfusion and plasma derived medicinal products.
  • Guarantee strict clinical confidentiality

Haematological Malignancies 

Include the following; 

  • Leukaemia – acute and chronic leukaemia
  • Lymphomas – Hodgkin’s and Non-Hodgkin’s lymphoma
  • Multiple myeloma

These are discussed in details under malignant disease chapter.