BLOOD TRANSFUSION

HEMATO - ONCOLOGY DIVISION

DEPARTEMENT OF CHILD HEALTH
MEDICAL SCHOOL
UNIVERSITY OF SUMATERA UTARA

TRANSFUSION

The decision to transfuse should not be based the haemoglobin

level alone, but also on a assesment of the childs clinical
condition.

Indication for transfusion :

Hb concentration of 4 g/dl or less
Hb concentration 4 -6 g/dl, if any of the clinical features of
hypoxia (acidosis, impaired conciousness),
hyperparasitemia (>20%).

TRANFUSION PROCEDURES
1.
2.

3.
4.
5.

If transfusion is needed, give sufficient blood the child

clinically stable.
5 ml/kg of red cells or 10 ml/kg whole blood increase Hb
concentration 2-3 g/dl unless there is continued bleeding or
haemolysis.
Where possible, use a paediatric blood pack & device to
control rate & volume of transfusion.
Transfusion should be given slowly e.g. 5 ml/kg of red cells
over 1 hour.
Give furosemide 1 mg/kg orally or 0.5 mg/kg Iv to max. dose
20 mg.kg cardiac failure & pulmonary oedema.
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TRANFUSION PROCEDURES
6.

7.
8.
9.

Monitor for signs of (cardiac failure, fever, respiratory disterss,

tachypnoea, hypotension, acute transfusion reaction, shock,
haemolysis, DIC).
Re-evaluate the patients Hb or Ht & clinical condition after
transfusion.
If still anemia, give a second transfusion of 5 10 ml/kg of red
cells or 10 15 ml/kg of whole blood.
Continue treatment of anemia to help haematological recovery.

APPROPRIATE & INAPPRORIATE TRANSFUSION

The safety & effectiveness of transfusion depend on

two key factors :
A supply of blood & blood products that are safe.
The appropriate clinical use of blood & blood products.

TRANSFUSION IS OFTEN UNNECCESSARY

FOR THE FOLLOWING REASONS :
The

need for transfusion can often be avoided by the

prevention or early diagnosis & treatment of anemia.
Blood is often unneccessarily given to raise a patients Hb
level before surgery or to allow earlier discharge from
hospital.
Patients transfusion requirment can often be minimized by
good anaesthetic & surgical management.
If blood is given when is not needed.
Bllos is expansive, scarce resource.
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THE RISK OF TRANSFUSION :

Red

cell transfusion :
The transfusion of red cell products carries a risk of
serious haemolityc transfusion reaction.
Blood products can transmit infection agents ( HIV,
hepattis B, hepatitis C, syphillis, malaria & Chagas
diseases to the recipient).
Any blood product can become contaminated with
bacteria.
Plasma transfusion :
Plasma can transmit most of the infection present in
whole blood.
Plasma can also cause transfusion reactions.
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BLOOD SAFETY
The quality & safety of all blood & blood products the
process from selection of blood donors to administration
patients, the requires :

The establishement of a well-organized blood transfusion

service.
The collection of bloood only from voluntary non-remunerated
donors.
The screening of all donated for transfusion transmissible
infections.
Good laboratory practice in all aspects of blood grouping,
compatibility testing, components preparation & storage of
blood & blood products.
A reduction in unneccesary transfusions.
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BLOOD PRODUCTS
Blood

product : Any therapeutic substance prepared from human

blood.
Whole blood : Unseparated blood collected into an approved
container containing an anticoagulant-preservative solution.
Blood component :
1. A constituent of blood, separated from whole blood, such as :
Red cell consentrate
Red cell suspension
Plasma
Platelet concentrates

2.
3.

Plasma or platelets collected by apheresis

Cryoprecipitate, prepard from fresh frozen
plasma (Factor VIII & fibrinogen).

Plasma derivate : Human plasma proteins prepared

under pharmaceutical manufacturing conditions,
such as :
Albumin
Coagulation factor concentrates
Immunoglobulins
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WHOLE BLOOD

450 ml WB donation contains :

450 ml donor blood
63 ml anticoagulant
No functional platelets
No labile coagulation factors (V & VIII)
Infection risk : HIV1, HIV 2, hepatitis, syphillis, malaria &
Chagas diseases.
Indications : Red cells replacement in acute blood loss with
hypovolemia, exchange transfusion.
Storage : +2 & +6 0C in blood bank, transfusion should be
started within 30 minutes of removal from refrigerator.
Complete transfusion within 4 hrs of commencement.
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PACKED RED CELLS

Infection risk : HIV1, HIV 2, hepatitis, syphillis, malaria &

Chagas diseases.
Indications : Red cells replacement in anemia, use crystalloid
replacement fluids or colloid solution in acute blood loss.
Storage : +2 & +6 0C in blood bank, transfusion should be
started within 30 minutes of removal from refrigerator.
Complete transfusion within 4 hrs of commencement.

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Guidelines for Pediatric RBC Transfusions

Children and Adolescent
Acute loss >25% circulating blood volume
Hemoglobin <8.0 g/dL* in perioperative period
Hemoglobin <13.0 g/dL and severe cardiopulmonary disease
Hemoglobin <8.0 g/dL and symptomatic chronic anemia
Hemoglobin <8.0 g/dL and marrow failure

Infants Within First 4 Mo of Life

Hemoglobin <13.0 g/dL and severe pulmonary disease
Hemoglobin <10.0 g/dL and moderate pulmonary disease
Hemoglobin <13.0 g/dL and severe cardiac disease
Hemoglobin <10.0 g/dL and major surgery
Hemoglobin <8.0 g/dL and symptomatic anemia

*Hematocrit estimated by Hb g/dL x 3

Strauss RG. Blood and blood component transfusion. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson
Textbook of Pediatrics. 16th ed. Philadelpia. WB Saunders Company, 2000.p.1499-150313

PLATELETS CONCENTRATES

Single donor unit in a volume 50 60 ml

of plasma.
Infection risk : HIV1, HIV 2, hepatitis, syphillis
malaria & Chagas diseases, bacterial contamination.
Indications : Trhrombocytopenia, platelets function defects.
Storage : Up to 72 hours at 20 - 24 0C with agitation, do not
store at 2 6 0C.
Complete transfusion within 4 hrs of commencement.

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Guidelines for Pediatric Platelet Transfusions

Children and Adolescent
PLTs <50 x 109/L and bleeding
PLTs <50 x 109/L and invasive procedure
PLTs <20 x 109/L and marrow failure with additional
hemorrhagic risk factors
PLTs normal with qualitative PLT defect and bleeding or
invasive procedure

Infants Within First 4 Mo of Life

PLTs <100 x 109/L and bleeding
PLTs <50 x 109/L and invasive procedure
PLTs <20 x 109/L and clinically stable
PLTs <100 x 109/L and clinically unstable

PLTs = platelets
15 HB, editors. Nelson
Strauss RG. Blood and blood component transfusion. In: Behrman RE, Kliegman RM, Jenson
th
Textbook of Pediatrics. 16 ed. Philadelpia. WB Saunders Company, 2000.p.1499-1503

FRESH FROZEN PLASMA

Contains normal plasma levels of stable clotting factors,

albumin , immunoglobulin, factors VIII and separated from
one whole blood .
Usual volume of pack 200 300 ml.
Infection risk : same as whole blood
Indications : Liver diseases, warfarin overdose, depletion od
coagulant factors, DIC, TTP.
Before use, should be thawed in blood bank in water is 30-37
0C. transfusion should be started within 30 minutes of removal
from refrigerator.
Complete transfusion within 4 hrs of commencement. Initial
dose 15 ml/kg.
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Guidelines for Pediatric FFP Transfusions

Infants, Children and Adolescent
Severe clotting factor deficiency and bleeding
Severe clotting factor deficiency and invasive procedure
Emergency reversal of warfarin effects
Dilutional coagulopathy and bleeding
Anticoagulant protein (AT-III), protein C and S) replacement
Plasma exchange replacement fluid for thrombotic
thrombocytopenic purpura

AT-IIII = Antithrombin III

Strauss RG. Blood and blood component transfusion. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson
Textbook of Pediatrics. 16th ed. Philadelpia. WB Saunders Company, 2000.p.1499-1503

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CRYOPRECIPITATE

Contains : The factors VIII 80-100 iu/pack,

fibrinogen 150-300 mg/pack.
Infection risk : as for plasma.
Indications : Von willebrand factor, factor VIII,
factors XIII, DIC.

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ALBUMIN

Preparation : 5% : 50mg/ml ;
20% : 200mg/ml; 25% : 250mg/ml.
Usual volume of pack 200 300 ml.
Infection risk : No risk of transmission viral infection.
Indications : Replacement fluid in therapeutic plasma
exchange, edema in nephrotic syndrome, ascites,
hypoalbuminemia.
Precaution : administration of 20% albumin may cause
pulmonary edema
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ORDERING BLOOD
Assess patients
need for transfusion

Emergency
Blood need
within 1 hr or less

Urgently request ABO

& RhD campatible units.
Blood bank may
select group O

Definite need
for blood
e.g elective surgery

Possible need
for blood
e.g. obstetrics,
elective surgery

Request ABO &

RhD compatible units
To be available
at stated time

Request group,
antibody screen
& hold
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MONITORING THE TRANSFUSED PATIENT

1. For each unit of blood transfused, monitor the patient :
Before starting the transfusion
As soon as the transfusion is started
15 minutes after starting the transfusion
At least every hours during transfusion
On completion of the transfusion
4 hours after completing the transfusion

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2. At each of the stages, record the following information on the

patients chart :
Patients general appearance
Temperature
Pulse
Blood pressure
Respiratory rate
Fluid balance (oral & IV fluid intake ; Urinary output)
3. Record :
Time the transfusion is started
Time tha transfusion is completed
Volume and type of all products transfused
Unique donation numbers of all products transfusion
Any adverse effects
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ADVERSE EFFECTS OF TRANSFUSION

Acute complications of transfusion
Category

Signs

Symptoms

Possible cause

MILD REACTION

Urticaria, rash

Pruritus

Hypersensitivity (mild)

MODERATELY
SEVERE REACTION

LIFE THREATENING
REACTIONS

Flushing,
Anxiety, pruritus,
Hypersensitivy, febrile nonurticaria, rigors, palpitations, mild
haemolytic transfusion
fever,
dyspnoe, headache
reaction. Contamination
restlessness,
with pyrogens/ or bacteria
tachycardia
Rigors, fever,
restlessness,
hypotension,
tachycardia,
Hburia,DIC

Anxiety, chest pain,

pain near infusion
site, respiratory
distress, back pain,
headache, dyspnoe

Acute intravascular
haemolysis, bacterial
contamination & septic
shock, fluid overload,
anaphylaxis, transfusionassociated acute lung injury
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Immediate management for transfusion reaction

Category
MILD
REACTION

Managements
1.
2.
3.

MODERATELY
SEVERE
REACTION

1.
2.
3.
4.
5.
6.
7.
8.

Slow the transfusion

Administer antihistamine IM (CTM o.1 mg/kg or equivqlent)
If no clinical improvement within 30 minutes or if signs & symptom worsen,
treat as category 2.
Stop the transfusion, replace the infusion set & keep IV line open with normal
saline
Notify the doctor responsible for the patients & the blood blank immediately
Send blood unit with infusionset, freshly collected urine & new blood samples
Administer antihistamine IM & oral or recta anipyretic.
Give IV corticosteroid & bronchodilator if there are anaphylactoid features.
Collect urine for next 24 hrs
If clinical improvement, restart transfusionslowly with new blood unit
In no clinical improvement within 15 minutes or if signs & symptoms worsen,
treat as category 3.
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Immediate management for transfusion reaction

Category
LIFE
THREATENING
REACTIONS

Managements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Stop the transfusion, replace the infusion set & keep IV line open with normal saline
Infuse NS (initially 20-30 ml/kg) to maintain systolic BP if hypotensions.
Maintain airway & give high flow oxygen by mask
Give adrenalin 0.01 mg/kg IM (as 1: 1000 solution)
Give IV corticosteroid & bronchodilator if there are anaphylactoid features.
Give diuretic (furosemide 1 mg/kg IV)
Notify the doctor responsible for the patients & the blood blank immediately
Send blood unit with infusionset, freshly collected urine & new blood samples
Check fresh urine specimen vissually for signs of Hburia
Start a 24 hrs urine collection & fluid balance
Assess for bleeding from puncture site or wounds
Reassess, if hypotension : (give further NS 20-3- ml/kg over 5 minuts; give inotrpe, if
available)
If UOP fallinf or alboratory evidence of acute renal failure : (Maintain fluid balance,
give furosemide, consider dopamine infusion, dialysis)
If bacterenia is suspected , start broad spectrum antibiotics IV.
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ADVERSE EFFECTS OF TRANSFUSION

Delayed complications of transfusion
Complications

Signs & symptom

Presentation

Treatment

Delayed haemolytic
reaction

Fever, anemia,
jaundice,
occasionally Hburia

5-10 days post

transfusion

Ussually not treatment; if

hypotension & oliguria, treat as
acute intravascular haemolysis

Post0transfusion
purpura

Increased bleeding
tedency,
thrombocytopenia

5-10 days post

transfusion

High dose steroid, Iv

imunoglobulin, Plasma exchange

Graft vs host
diseases

Fever, skin rash,

desquamation,
diarrhoea, hepatits,
pancytopenia

10-12 days post

transfusion

Usually fatal, supportive care, no

specific therapy

Iron overload

Cardiac & liver

failure in transfusiondepents patients

Prevent with iron-binding

agents(desferoxamine)

Transfusion
HIV 1, HIV 2, Hepatitis B, C; Syphillis, Chagas diseases, Malaria,
transmitted infections cytomegalovirus, brucellosis, etc.

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FACTORS DETERMINING FOR TRANSFUSION

Blood loss
External bleeding
Internal bleeding non traumatic (peptic ulcer, varices,
ectopic pregnancy, antepartum hemorrhage, ruptured
uterus)
Internal bleeding traumatic (chest, spleen, pelvis, femur)
Haemolysis
Malaria
Sepsis
DIC
Cardiorespiratory state & tissue oxygenation
Anemia
Anticipated need for blood (surgery & anaesthesia)
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