Transfusion

Transfusion is the transfer of blood products or blood derivatives from a healthy individual/donor to a patient/recipient to supplement the recipient's blood or its components.

Procedures connected with blood collection, testing, processing, storage and distribution of human blood and its components are subject to legislative regulation (specifically Decree No. 130/2018 Coll. Laying down additional requirements for the quality and safety of human blood and its components).

Transfusion indications

  • heavy loss of blood (injury, surgery, parturition, chronic haemorrhagic loss)
  • anaemia, thrombocytopenia
  • hypoxia, shock, intoxication
  • burns
  • oncologic diseases, chronic kidney and liver diseases
  • blood clotting disorders

The “4C method” must be followed:

  • correct indication
  • correct blood product
  • correct time
  • correct amount

Types of transfusion

  • Allogeneic transfusion – use of blood products and blood derivatives processed from donor blood.
  • Autologous transfusion (autotransfusion) – a patient's own blood is collected and reinfused (preoperative blood collection: the patient donates 1–3 blood transfusion units 3–4 weeks before surgery)
  • Perioperative and postoperative recuperation – a patient's own blood is sucked from the operating field during surgery with a special device and immediately returned to the blood stream
  • Exsanguinating transfusion – neonatal red cell exchange transfusion in foetal erythroblastosis (maternal and foetal Rh incompatibility. An Rh negative mother creates antibodies against red blood cells of an Rh positive foetus, leading to severe haemolysis of foetal erythrocytes. Blood cell losses in the foetus caused by haemolysis are compensated for by increased haematopoiesis. Immature erythroblasts are released (this is called foetal erythroblastosis). Re-exsanguinating transfusion – repeated neonatal red cell exchange transfusion
  • Intrauterine transfusion – exchange of foetal blood

Blood products

  • prepared in plastic bags at "blood banks"
  • released on request
  • must respect ABO system (blood group A, B, AB, 0) and Rh compatibility
  • the amount of a blood product is stated in transfusion units (T. U. = transfusion unit = the amount of blood product resulting from the processing of one standard full blood collection)
DESIGNATION OF BLOOD PRODUCT CHARACTERIZATION
Whole blood
  • currently used only in exceptional cases
  • indication: Massive blood loss
Packed RBCs
  • blood from which part of the plasma has been removed; it has high haematocrit (0.65–0.75)
  • 1 TU = 250–300 mL
  • indication: anaemia
  • it flows slowly (high density), so it is not suitable for quick delivery during massive bleeding
Resuspended RBCs (leukocytes reduced)
  • red blood cells diluted with resuspension solution, free of leucocytes
  • indication: the most frequently used blood product in therapy of surgical bleeding, anaemia, in haemato-oncology and paediatrics; compensates for the loss of RBCs, haemoglobin and lost volume
Washed RBCs
  • RBCs without buffy coat (via plasma aspiration, washed with normal saline solution, and supplemented with a resuspension solution)
  • indication: When there is a risk of immunological response to the plasma components
Platelet concentrate
  • indication: thrombocytopenia, thrombocytopathy
  • always freshly prepared, kept for 5 days under constant stirring at 22 °C
Plasma
  • fresh frozen plasma, 1 TU = 200–280 mL
  • must be defrosted before delivery
  • indication: refill of circulating blood volume and substitution of coagulation factors
  • plasma components:
    • albumin – volume expander, used to increase intravascular volume of circulating blood
    • fibrinogen – used in case of bleeding due to native fibrinogen loss
  • specific globulins are prepared from plasma for immunological purposes
  • for clinical use, six months quarantine is required in order to reduce the risk of infectious disease transmission. Plasma is ready for use after the donor is repeatedly examined six months after the collection and found negative for HIV, syphilis, and hepatitis B and C

Designation of blood products

  • title
  • blood group and Rh factor
  • volume
  • composition and amount of preservative solution
  • date and blood sampling number
  • donor identification number
  • guarantee of negativity of performed tests
  • expiration date
  • storage conditions
Blood products – plasma and resuspended RBCs (leukocytes reduced)
Blood products – plasma and resuspended RBCs (leukocytes reduced)
Blood products – plasma and resuspended RBCs (leukocytes reduced)
Blood products – plasma and resuspended RBCs (leukocytes reduced)
Blood products – plasma and resuspended RBCs (leukocytes reduced)
Blood products – plasma and resuspended RBCs (leukocytes reduced)

Ordering a blood product

  • request form for a blood product and immuno-haematological examination (the request form must be accompanied by a sample tube containing recipient's non-coagulable venous blood for blood group and Rh factor examination and for the compatibility test (one blood sample is sufficient to order 2–3 bags of a blood product
  • blood product is ready:
    1. STATIM – within 90 minutes after recipient´s blood acceptance
    2. VITAL INDICATION – as soon as possible after a physician's phone call
    3. PLANNED – by the date and time written on the request form

Principles of administering a blood product

  • the blood product should be administered within two hours of dispatch
  • introduction of the transfusion kit (transfusion set) should be performed just prior to administration
  • when administered, the product should be at room temperature
  • if a central venous catheter is introduced, only the specified entry for the administration is used
  • no other drugs are administered at the same time; the blood product must be given separately
  • when using an overpressure transfusion, carefully monitor the progress (there is an increased risk of haemolysis, embolism, peripheral venous input port damage, and circulatory overload)
  • used bags of blood product must not be kept; return them to the blood bank

Preparation of equipment

  • blood product with dispatch form
  • written consent for transfusion in patient's documentation
  • original documentation of the patient's blood group
  • a transfusion record book
  • Sanguitest (ABO test, Bed-side test)
  • capillary blood collection aids
  • equipment for intravenous input introduction (if it has not already been introduced)
  • equipment for vital signs measurement (tonometer, stethoscope, thermometer)
  • non-sterile urine tube and diagnostic urine test strips
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration
Preparation of equipment for Resuspended (leukocytes reduced) RBCs administration

Nurse's intervention

  • Check the data on the bag containing the blood product and on the dispatch form.
  • Check the original documentation of the patient's blood group.
  • Visually inspect the blood product.
  • Prepare patient's documentation.
  • Prepare a transfusion record book (a registry of blood products and blood derivates applied in the past).
  • Measure and record vital signs.
  • Collect urine for indicative biochemical examination (testing for the presence of proteins and blood).
  • Call the physician: to check the bag, dispatch documentation, blood group, Rh factor, identification number of the product, expiration date, quantity and type of the product; make sure the patient's name, blood group and Rh factor match the patient's original documents).
Transfusion record book (book is paginated; pulling out the pages or altering the records is strictly prohibited)
Transfusion record book (book is paginated; pulling out the pages or altering the records is strictly prohibited)
Transfusion record book (book is paginated; pulling out the pages or altering the records is strictly prohibited)

Sanguitest (AB0 test, Bed-side test)

  • a blood group reassurance test performed at the patient's bed using a diagnostic kit; performed by a physician; the capillary blood of the recipient and the blood from the blood product is assessed using test serum and final agglutination is evaluated
Sanguitest tools
Sanguitest tools
Sanguitest tools
Sanguitest tools
Sanguitest tools
Sanguitest tools
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 1
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 2 – Mixing
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
Performing a Sanguitest at a patient's bed 3 – Evaluating the result
  • the result of the Sanguitest must be recorded in the patient's documentation
  • the physician certifies by signature that the blood product has been checked, that the blood groups are compatible, and that the Sanguitest results are correct
  • nurse adjusts the transfusion rate (between 1.5 to 2 hours), writes down the time the transfusion started, and regularly checks the transfusion rate

Nurse's intervention after blood product administration

  • ending the administration, leaving venous port in situ
  • measurement of vital signs
  • repeating the urine sample collection for indicative biochemical examination (testing for the presence of proteins and blood)
  • designation of the transfusion bag and transfusion kit; storing them in the refrigerator for 24 hours (in case of a post-transfusion reaction)
  • completing the records in the documentation and confirming by signature: the administration of the blood product, the commencement and completion time of the transfusion, the course of administration, the amount of product administered, any occurrence of post-transfusion reactions

Transfusion reactions

  • acute or delayed
  • nurse immediately interrupts the administration of the transfusion (but keeps the intravenous input port), calls the doctor, measures vital signs, follows the physician's orders, fills out an adverse event report

Haemolytic transfusion reaction (the most serious transfusion-related complication)

  • cause – incompatibility between the blood group of the product and that of the recipient
  • symptoms – increased temperature; increased heart rate; sensation of heat and pain along the vein receiving the blood; chills; shivering; dyspnoea; bronchospasm; headache; lower back pain; nausea; vomiting; oliguria; anuria; renal failure; shock status
  • a strong reaction within 15 minutes of transfusion commencement (with only 10–50 mL of the blood product administered)

Febrile reaction (the most common)

  • cause – pyrogen content in the blood product
  • symptoms – rapid increase of body temperature, any time from 30 minutes up to 6 hours after completion of transfusion administration; chills; headache; nausea; vomiting; tachycardia; muscle pain
  • progress is usually mild
  • a fever of 38 °C is considered serious

Allergic reaction

  • cause – hypersensitivity to components in the blood product (allergens, antibodies) or to anti-coagulable agents or preservatives
  • symptoms – mucosal oedema; nettle-rash; increased body temperature; headache; diarrhoea; dyspnoea

Anaphylactic reaction

  • symptoms – manifests within a few minutes after commencement of transfusion (cardiovascular collapse; respiratory distress; anaphylactic shock)

Circulatory overload / hypervolemia

  • cause – fast administration, deteriorated renal functions
  • result – heart failure and pulmonary oedema
  • symptoms – breast pain; shortness of breath; aggravated anxiety; psychomotor agitation; visible increase of neck vein filling; cyanosis; tachycardia

Bacterial contamination and septic shock

  • cause – contamination of the blood product
    • bacteria from the donor's skin during blood collection (skin Staphylococci)
    • bacteria in the donor's blood at the time of blood collection (Yersinia)
    • incorrect handling during blood product processing
    • damage of the plastic bag containing blood product
    • contamination before administration
  • symptoms – increased body temperature; chills; hypotension

Plasma Administration

  • The duties of the nurse and physician when administering the plasma are the same as those used for blood transfusion, except the Sanguitest is not performed.
Equipment for plasma administration
Equipment for plasma administration
Equipment for plasma administration
Equipment for plasma administration
Equipment for plasma administration
Equipment for plasma administration

Blood derivatives

  • pharmaceutically manufactured medical products made of plasma taken from several donors
  • plasma is processed into the finished blood derivative by fractionation at specialized fractionation centres
TITLE OF BLOOD DERIVATIVE CHARACTERIZATION
Albumin
  • indication: albumin supplementation before and after surgery; treatment of hypovolemic states (haemorrhagic shock, burns); renal and hepatic failure; low level of albumin in plasma
  • principles:
    • do not administer the product with other medicines, blood products or blood derivatives
    • administer immediately after opening
Immunoglobulins
  • IVIG – for I.V. administration
  • SCIG – for S.C. administration
  • IMIG – for I.M. administration
  • indication: therapeutic (infections, immunity disorders); prophylactic (vaccination)
  • e.g. in Rh negative mothers we administer the following: anti-D (IMIG, IVIG); hepatitis B (IMIG, IVIG); tetanus (IMIG); rabies (IMIG); cytomegalovirus (IVIG)
Concentrated coagulation factors
  • factor VIII (antihaemophilic globulin); factor IX
  • indication: haemophilia (congenital bleeding disorder – type A, B)
Human fibrinogen
  • indication: blood diseases
Antithrombin III
  • a physiological coagulation inhibitor
  • indication: acquired bleeding disorders; absence of antithrombin III (major injuries, sepsis, disseminated intravascular coagulation, hepatopathy, nephrotic syndrome)

Literature

  • Řeháček V, Masopust J. a kol. Transfuzní lékařství, Praha: Grada Publishing, Czech Republic, 2013. ISBN 978-80-247-4534-3.
  • Decree No. 130/2018 Coll., of 19 June 2018, amending Decree No. 143/2008 Coll., laying down additional requirements for the quality ans safety of human blood and its components. In: Sbírka zákonů České republiky. 2018, amount 66, pp. 1702-1706. ISSN 1211-1244.