Date : Saturday, 15 Dec., 2018
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Rational Use of Blood  
RATIONAL USE OF BLOOD
Dr. Tulika Chandra, MD
Head
"State of Art Model Blood Bank"
Department of Transfusion Medicine
K.G. Medical University, Lucknow, India
 
The aim is to provide the right blood product, in the right quantity, for the right patient.

The appropriate use of blood and blood and blood products can be defined as "Transfusion of safe blood products only to treat conditions leading to significant morbidity or mortality that cannot be prevented or managed effectively by other means"

TRANSFUSION SHOULD NOT BE THE FIRST CHOICE - WHY?

The answer lies in the fact that it carries risk of adverse reactions (acute and delayed
complications) and transfusion transmissible infections (TTI). Besides this plasma transmit
most of infections present in whole blood.

Appropriate and inappropriate transfusion

Which blood to transfuse?

  • Blood from appropriately selected donors (Voluntary non renumerated donors) should be transfused
  • Blood should be screened for TTI
  • Compatible blood should be transfused to the patient

When transfusion may be unnecessary?


  1. Transfusion can be avoided / minimized by prevention / early diagnosis and treatment of anemia and conditions causing it. Transfusion is only needed if effects of chronic anemia are severe enough to require rapid raising of hemoglobin level
  2. Blood is often unnecessarily given to raise a patient's hemoglobin before surgery or allow early discharge from hospital. These are rarely valid reasons for transfusion
  3. Transfusions of whole blood, PRBC, plasma are given when other treatments such as infusion of normal saline or other intravenous replacement fluids would be safer, less expensive and equally effective for treatment of acute blood loss
  4. Transfusion requirements may be minimized by good anesthetic and surgical management. The techniques to minimize blood loss during surgery should be used. Stop anticoagulant/antiplatelet drugs if safe before planned surgery. Alternative approaches such as desmopressin, aprotinin or erythropoietin can be used.
  5. If blood is given when not needed, patient receives no benefit and is exposed to unnecessary risk.
  6. Blood is an expensive, scarce resource. Unnecessary transfusions cause shortage
    of blood and blood products for patients in real needs but Safe blood products used correctly can be lifesaving
CLINICAL TRANSFUSION PROCEDURES
  1. Getting right blood to the right patient at the right time
    • Assess patients clinical need for blood and when it is required
    • Inform the patients / relatives about the proposed transfusion treatment and put it in recording
    • Record the indications for transfusion
    • Select the blood product and quantity required
  2. Complete the blood request form accurately and legibly
    • Patients identity name, ward, bed no.
    • Product and no. of units required
    • Reason for transfusion
    • Urgency of patients requirement for transfusion
  3. Obtain and correctly label a blood sample for compatibility testing.
    • Patients blood sample is placed in a sample tube correctly labeled and uniquely identifiable with the patient.
    • All details on the blood sample tube match those on the blood request form and are uniquely identifiable with the patient.
    • Send blood request form and blood sample for compatibility testing.
    • Laboratory performs pretransfusion antibody screening.
    • Safe transfusion depends on avoiding incompatibility between donors red cells and antibodies in patients plasma.
Record patients note
  • Type and volume of product transfused
  • Unique donation no. of each unit transfused
  • Blood group of each unit transfused
  • Time at which transfusion commenced
  • Signature of person administering the blood
Monitor the patient before, during and on completion of the transfusion
  • Record the completion of transfusion
  • Identify and respond immediately to any adverse effects
Key Points
  • Every hospital should have standard operating procedures for each stage of clinical transfusion process and all staff trained in it.
  • Communication is essential between clinical and blood bank staff
  • Blood bank cannot issue blood without correctly labelled sample and blood requisition form
  • Blood products must be kept in correct storage condition in clinical area before transfusion
  • For each transfusion patient must be monitored by trained member of staff.
AIM OF BLOOD ORDERING
Responsibility of the clinician
  • Correctly complete the blood request form with three patients identifiers
  • Collect the blood sample from the right patient in the right sample tube and correctly label the sample tube
  • Provide the blood bank with clear information on
  • The products and no. of units required
  • Reason for transfusion
  • Urgency of patients requirement for transfusion
  • When and where blood is required
  • Who will deliver or collect blood
Assess Patients need for transfusion
Emergency Definite need Possible need
< 1 hr elective surgery obstetrics, elective
ABO / Rh Compatible
(O group)
ABO / Rh available group requested
Ab screen and hold
Blood ordering schedule
Develop a blood ordering schedule which is a guide to normal transfusion requirements for
common surgical procedures.

Ordering blood in an emergency

  • Clear and simple procedures. Insert iv canula for sampling. Set iv infusion of N saline / balanced salt solution.
  • Clearly label blood sample tube and blood request form. If patient is unidentified use
    emergency admission no.
  • If another request has to be send use same identifiers as on the first request form and blood sample so blood bank knows they are dealing with same patient.
  • If several staff working on emergency cases, one person should take charge of ordering blood. Urgency of blood requirement to be communicated by predecided words.
  • Blood bank may send group O (possibly neg 0 bld) if there is any risk of patient identification. Safest way to avoid serious mismatch
Precautions
  • If the patient is conscious ask him details of name etc. In unconscious patients ask relatives or second member of staff. Blood sample is taken in tubes / vials and labelled with patients name, ward, bed no, date, signature of person taking sample.
    Ensure patients name is spelt correctly. Do not label tubes before taking blood sample or patients blood may be put in wrong tube
  • If patient needs further red cell transfusions send new samples for compatibility testing. Fresh blood sample ensures that patient does not receive incompatible blood.
    Misconceptions and Myths regarding blood transfusion are present. These have
    to be removed by the following awareness
  • Fresh" Blood: No. concept of fresh blood is present in transfusion medicine.
  • Single Unit Transfusion should not be done.
  • Empirical Transfusion should not be done.
  • Nutritional Anemia is not an indication for blood transfusion.
  • Pre Surgical, Wound Healing and Enhancement of well being are not indications for blood transfusion.
Checklist for clinicians
  • What improvement in patients clinical condition I am aiming to achieve?
  • Can I minimize blood loss to reduce patients need for transfusion?
  • Are there any other Treatment I can give (IV replacement fluids) before deciding to transfuse?
  • What are specific clinical / lab indications for transfusion of this patient?
  • What are risks of transmitting TTI?
  • Do benefits of transfusion outweigh the risk for this particular patient?
  • What other options if no blood is available in time?
  • Have I recorded my decision and reasons for transfusion on patients chart and blood
    request form?
  • If still in doubt ask yourself?
    If this blood was for myself or my child would I accept the transfusion in these
    circumstances?
 
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