TRANSFUSION MEDICINE: EVERYTHINGYOU NEED TO KNOW!

-Sai Lavanya Patnala, Intern, Apollo Institute of Medical Sciences and Research, Hyderabad

WHAT IS TRANSFUSION?

Transfusion is the intravenous infusion of whole blood or blood products. Blood can be transfused in the form of whole blood or fractionated blood components, which are prepared by separating whole blood into its constituent elements and storing each under ideal conditions. These components include:

1. Packed red blood cells
2. Platelet transfusion
3. Fresh frozen plasma (FFP)
4. Cryoprecipitate
5. Plasma derivatives including clotting factors.

HISTORY

The first documented references go to Ovid who wrote in 43 BC in the seventh book of the Metamorphoses about the use of blood. The ancient kings of Egypt apparently bathed in blood, with the belief such baths can resuscitate the sick and rejuvenate the old. In 1492, blood was taken from three young men and given to the stricken Pope Innocent VII in the hope of curing him. It is the first time a blood transfusion was recorded[4].

In the 1600s, William Harvey demonstrated how the circulatory system functioned. Shortly after that, scientists became interested in transfusion, initially transfusing animal blood into humans. Dr. Philip Syng Physick carried out the first human blood transfusion in 1795, and the first transfusion of human blood for treating hemorrhage happened in England in 1818 by Dr. James Blundell[1].

He successfully transfused human blood to a patient who had hemorrhage during childbirth. The modern transfusion era started with the discovery of three main human blood groups A, B, and C by Karl Landsteiner, an Austrian physician, in 1901. Later C group changed to O. In the coming years, progress has been made in storage, collection, preservation, and distribution of blood by scholars, doctors, and researchers of many nationals. During the Second World War with the invention of Coombs test, a new era in transfusion therapy begins. After 1960 with the invention of use of plastic bags and plasmapheresis, blood component therapy has been started all over the world. For safe transfusion of blood and components, test for hepatitis B and C and HIV 1 and 2, serological test for syphilis, and other tests have been introduced[4].

INDICATIONS

Indications for RBC transfusion are not determined solely by Hb value, but rather by an assessment of the clinical circumstances and the patient’s overall condition.

• Hemorrhagic shock or ongoing rapid blood loss
• Exchange transfusion: e.g., in severe sickle cell disease or methemoglobinemia
• Anemia, especially if Hb ≤ 7 g/dL or Hb ≤ 8 g/dL with preexisiting cardiovascular disease or if the patient is due to undergo cardiac or orthopedic surgery
• For the treatment and prevention of active bleeding such as in severe thrombocytopenia, platelet transfusion is done
• In patients with bone marrow failure, prophylactic platelet transfusion is indicated
• Clotting factor deficiencies are treated by transfusion of cryoprecipitate which contains clotting factors like fibrinogen, factor VIII, factor XIII along with vWF and fibronectin[2]

CONTRAINDICATIONS

There are no absolute contraindications, but some patients or their patients (in pediatric cases) may refuse to receive transfusions on religious grounds.[3]

Do not use platelet transfusions to treat severe thrombocytopenia due to ITP, TTP, HUS, or HIT unless there is major bleeding.

PROTOCOL

The suggested supplies for a blood transfusion may include the following:

• IV access: 20-22 gauge for routine transfusions in adults.16-18 gauge for rapid transfusions in adults.22-25 gauge for pediatrics.
• Administration sets: The requirements for these sets might vary from facility to facility
• A blood filter, which may range in pore size from 170 to 260 microns. It’s intended to remove clots, cellular debris, and coagulated protein.
• Infusion devices can be used to transfuse blood components (i.e. infusion pumps, rapid infusers, blood warmers, and pressure devices). A pressure infusion device may be used for the rapid administration of blood components.
• A blood warmer device is often used to prevent hypothermia during rapid administration of cold-blood components, such as the operating room or a trauma setting.

Here are some of the general guidelines you should follow when performing a blood transfusion in a controlled setting.

Before the Transfusion

• Find current type and crossmatch
• Obtain informed consent and health history
• Obtain large bore IV access. Each unit will be transfused within 2-4 hours
• Obtain a second IV access if the patient requires additional IV medication therapy (i.e. antibiotics)
• Remember: Normal saline is the only solution that can be transfused with blood products
• Assemble supplies like Special Y tubing with an in-line filter, 0.9% NaCl (Normal Saline) solution and a blood warmer
• Obtain baseline vital signs and notify the doctor if their temperature is greater than 100° F
• Obtain blood from blood bank. Packed red blood cells (pRBCs) can only be hung ONE UNIT AT A TIME.
• Remember: Once the blood has been released for your patient, you have 20-30 minutes to start the transfusion and up to 4 hours to complete the transfusion

Initiating the Blood Transfusion

• Verify Blood Product by crosschecking the Patient’s name, date of birth, and medical record number, Patient’s blood type versus the donor’s blood type and Rh-factor compatibility and Blood expiration date
• Educate the patient and relay the signs and symptoms of a transfusion reaction like rash, itching, elevated temperature, chest/back/headache, chills, sweats, increased heart rate, increased respiratory rate, decreased urine output, blood in urine, nausea, or vomiting
• Assess and document the baseline vital signs (HR, RR, Temp, SPO2, BP), lung sounds, urine output, and color
• To start the blood transfusion, prepare the Y tubing with normal saline and have the blood ready in an infusion pump. Run the blood slowly for the first 15 minutes (2mL/min or 120cc/hr).
• Stay with the patient for the first 15 minutes; this is when most transfusion reactions can occur. Increase the rate of transfusion after this period if your patient is stable and doesn’t display signs of a transfusion reaction.
• Document vital signs after 15 minutes, then hourly, and finally, at the completion of the transfusion.

During the Transfusion

Look for any transfusion reactions( Ex: Allergic, febrile, GVHD (Graft vs. Host Disease),TRALI (Transfusion Related Acute Lung Injury). If you suspect a reaction, do the following:

1. Stop the transfusion IMMEDIATELY
2. Disconnect the blood tubing from the patient
3. Stay with the patient and assess their every five minutes
4. Notify the doctor and prepare for further doctor’s orders
5. Document everything

After the Transfusion

• Flush Y tubing with normal saline
• Dispose of used Y tubing in a red biohazard bin
• Obtain post-transfusion vital signs and document the patient’s status

After the procedure, patients may experience some soreness near the puncture site, but this side effect should dissipate quickly. While this is typically a low-risk procedure, serious blood transfusion risks or complications can include some of the following conditions such as Allergic reactions, fever, Acute immune hemolytic reaction, blood-borne infections. However, the most common reaction to a blood transfusion is mild soreness around the IV site.[5]

COMPLICATIONS

There are multiple complications of blood transfusions, including infections, hemolytic reactions, allergic reactions, transfusion-related lung injury (TRALI), transfusion-associated circulatory overload, and electrolyte imbalance.

• Febrile Reactions: Transfusing with leukocyte-reduced blood products may help reduce febrile reactions. If this occurs, the transfusion should be halted, and treatment is with acetaminophen and, if needed, diphenhydramine for symptomatic control. After treatment and exclusion of other causes, the transfusion can be resumed at a slower rate.
• Transfusion-associated Circulatory Overload: It is characterized by respiratory distress secondary to cardiogenic pulmonary edema. This reaction is most common in patients already in a fluid-overloaded state, such as congestive heart failure or acute renal failure. Diagnosis is based on symptom onset within 6 to 12 hours of receiving a transfusion, clinical evidence of fluid overload, pulmonary edema, elevated brain natriuretic peptide, and response to diuretics.Preventive efforts and treatment include limiting the number of transfusions to the lowest amount necessary, transfusing over the slowest possible time, and administering diuretics before or between transfusions.
• Allergic Reaction: It often manifests as urticaria and pruritis and occurs in less than 1% of transfusions. More severe symptoms, such as bronchospasm, wheezing, and anaphylaxis, are rare. This can be avoided by washing the plasma from the cells prior to transfusion.
• Transfusion-related Lung Injury (TRALI): This is uncommon, occurring in about 1:12,000 transfusions. Patients will develop symptoms within 2 to 4 hours after receiving a transfusion. Patients will have pulmonary edema, normal CVP, without evidence of left heart failure CVP. Diagnosis is made based on a history of recent transfusion, chest x-ray with diffuse patchy infiltrates, and the exclusion of other etiologies. While there is a 10% mortality, the remaining 90% will resolve within 96 hours with supportive care only.Infections: The risk of infections has decreased due to the screening of potential donors.Bacterial infection can also occur, but does so rarely, about once in every 250,000 units of red cells transfused.Fatal Hemolysis: This is extremely rare, occurring only in 1 out of nearly 2 million transfusions and results from ABO incompatibility. Patients will develop an acute onset of fevers and chills, low back pain, flushing, dyspnea as well as becoming tachycardic and going into shock. Treatment is to stop the transfusion, leave the IV in place, intravenous fluids with normal saline, and keep urine output greater than 100 mL/hour, diuretics may also be needed. Cardiorespiratory support may be provided as appropriate.
• Electrolyte Abnormalities: These are rare and more likely associated with large volume transfusion.
  • Hypocalcemia
  • Hyperkalemia
  • Hypokalemia

CONCLUSION

Our understanding of blood transfusion has improved dramatically over the past three decades. While blood products do have a benefit, they can also cause harm. Interprofessional team collaboration is crucial in managing patients undergoing blood transfusions and those having adverse reactions to transfusions. The key is to reduce the harm from unnecessary blood transfusions.

REFERENCES

1. Lotterman S, Sharma S. Blood Transfusion. 2022 Jun 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29762999.
2. https://next.amboss.com/us/article/2M0TLg?q=transfusion#Z0d767a500a4efcb1314a93ab2616de44
3. Conti A, Capasso E, Casella C, Fedeli P, Salzano FA, Policino F, Terracciano L, Delbon P. Blood Transfusion in Children: The Refusal of Jehovah’s Witness Parents’. Open Med (Wars). 2018;13:101-104
4. https://link.springer.com/chapter/10.1007/978-981-15-8435-0_9
5. https://www.unitekcollege.edu/blog/a-step-by-step-guide-to-blood-transfusion/