__________________________________________________________________________

NATIONAL BLOOD AND BLOOD PRODUCT TRANSFUSION POLICY

PURPOSE AND SCOPE

The purpose of this guideline is to provide guidance to all health workers in all three
medical divisions who deal with transfusion of blood and blood products, on the proper
management of blood transfusion and processes to follow in order to minimise the risks
and prevent complications associated with transfusion of blood and blood products.

The scope of its implementation will be the standard practice adopted in all health
facilities in Fiji, where blood transfusion takes place.

The guideline is divided into parts for ease of reference and applicability.

INTRODUCTION

In 2006, of a total of 4352 cross–match procedures undertaken at the Lautoka Hospital

Laboratory, a total of 4255 packed cells and 97 whole blood units were issued for
transfusion.

421 blood products such as Fresh Plasma, Fresh Frozen Plasma, Cryoprecipitate and
Platelet Concentrate were issued for transfusion.

15 Transfusion Reactions were reported to the Lautoka Hospital Pathology Laboratory in

2006. Investigations revealed that errors in the requesting, supply, and administration
have lead to significant risks to patients.

Although previous attempts have been made to rectify certain areas, these guidelines
have been inadequate in improving the processes and addressing the deficiencies
identified in the whole process of collection of blood samples, labelling, requesting,
supply, administration and monitoring of practice.

This guideline provides clear instructions and recommendations on the processes and
practices to be followed when transfusion of blood and/or blood products is offered as
treatment to a patient.

Where applicable, the guideline has delegated responsibility to appropriate officers to

fulfil various roles and functions relevant to their expertise to ensure that at all times,
quality service is provided through getting the Right Blood to the Right Person at the
Right Time.

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The processes endorsed in this guideline are discussed under the following major
headings:

I. Requests for Blood Transfusion and Collection of Blood Sample

II. Blood Grouping and Cross-Matching at Blood Bank
III. Storage of Blood
IV. Issue of Blood and Blood Products and Delivery to the Ward or Theatre
V. Commencement and Documentation of Transfusion
VI. The Care and Monitoring of Transfused Patients
VII. Unused Blood and Blood Products
VIII. Adverse Effects of Transfusion
IX. Reporting of Adverse Events
X. Training

I. REQUESTS FOR BLOOD TRANSFUSION AND COLLECTION OF BLOOD

SAMPLE.

1. Who requests for transfusion?

It is the responsibility of the medical officer [intern/ registrar/ consultant/

treating doctor at Subdivisional Hospital] to request for blood transfusion.

2. The Requesting Doctor’s Role

The medical intern or doctor’s role comprises the following:

a. Patient’s Consent

Once the decision to transfuse is made, it is the responsibility of the treating

doctor to explain to the patient the following:

i) Advantages of transfusion
ii) Adverse effects of transfusion
(Refer to Appendix 7 and Appendix 10)

And secure the patient’s consent by signing the appropriate consent form.

A copy of the ‘Consent For Receipt of Blood and Blood Products’ Form is
appended

Cultural and religious beliefs and wishes of the patient must be respected
at all times.

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 b. Patient Identity

Verify the identity of the patient by confirming with the patient if the patient is
conscious and a relative or second member of staff if the patient is unconscious
the following:

i) Patient’s Name
ii) Father’s Name
iii) Date of Birth
iv) Hospital Number

c. Requisition Form

Ensure that the completed requisition form has the following detail:

i) Correct Patient Name

ii) History - diagnosis/ reason for transfusion, relevant medical history,
previous transfusion/ antibodies
iii) Request - Products required, amount, time and date required
iv) Name of requesting clinician
A copy of the Requisition for Blood or Blood Products for Transfusion is
appended.

d. Labelling of Sample

The responsibility for correct and complete labelling of samples lies with the
person taking the blood sample.

Label the sample bottle correctly at the patient’s bedside with the label containing
the:

i) Patient’s first name, and Family name or Father’s name

ii) Date of Birth
iii) Gender
iv) Hospital Number
v) Name of Ward where patient is admitted

The information on the tube must correspond with the information on the
Requisition Form because the details on the compatibility label are copied from the
request form.

The blood bank will issue blood that is compatible with an identified sample.

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 Note:
i) To minimise error, it is recommended that the tube be not labelled prior to
obtaining the specimen. This will lessen the risk of putting a patient’s
blood sample into someone else’s labelled tube.

ii) Blood bank staff will not accept a request for compatibility testing when
either the blood request form or the patient blood sample is inadequately
identified, or the details do not match.

iii) Laboratory technicians are not authorised to amend or add the details of a
patient on the Request Form or the Specimen tube.

e. Urgent Requests

The blood bank should be alerted by phone if the blood is needed urgently. The
recipient’s blood sample should be taken down to the laboratory as soon as
possible.
Refer to form in Appendix 1.

The availability of blood and its collection from the blood bank will also be
confirmed by phone in all emergency cases.

f. Elective Requests

These requests will be processed through the normal process i.e. the use of the
appropriate forms for requisition and issue of blood and blood products, and do
not require the blood bank to be alerted by phone.
Refer to appended copies of the forms.

g. When Transfusion is Planned

In all cases where a transfusion is planned, request for grouping and

compatibility testing should be made at least 24 hours before the time of
transfusion. Cross match for elective cases therefore should not be done after
normal working hours.

Family donors when desirable should be arranged 72 hours in advance.

h. For Major Surgical Operations

All cases booked for major surgical operations should be grouped when they are
first seen in the clinic and placed on the waiting list. This allows for testing of
atypical antibodies at the time and also serves as a check when the patient is
regrouped on admission.

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 i. How much Blood and Blood Products to Request?

The blood bank has a list of recommended amount of blood to cross match for
various operations – the Maximum Blood Order Schedule (MBOS). It is intended
for the guidance of junior medical staff in order to achieve economical and
consistent blood ordering practice.

All requests for blood should follow this guideline. When in doubt, seek advice
from your consultant or the blood bank. These recommendations can be
overridden at the discretion of the surgeon or anaesthetist.
Copy of the MBOS is appended.

II. BLOOD GROUPING AND CROSS MATCHING AT BLOOD BANK

1. Grouping and Cross-match

Complete grouping and cross matching takes at least ONE AND A HALF
HOURS. This may take longer if atypical antibodies are found where compatible
blood has to be found.

Donor Blood is not considered to be safely cross-matched, unless the full

routine technique is used.

In very urgent cases times can be shortened (10-15 minutes) to obtain ABO
compatible blood.

It is the responsibility of the doctor in charge of the patient to define the degree
of urgency, to ask if necessary for emergency tests and to accept their
limitations.

2. Group and Hold

After the initial grouping and cross match, the laboratory will hold the patients
serum for one week.

If Transfusion has occurred, a fresh blood sample will be required for new cross
matching if the request is made 3 or more days after a transfusion. This is because
new antibodies may have developed after the last transfusion.

3. Blood Supply

GROUP ‘O’ RHESUS NEGATIVE BLOOD IS CONSTANTLY IN SHORT

SUPPLY and at Lautoka Hospital, delays in the provision of this Blood Group (O –
ve) should be anticipated with any request.

Supplies of blood groups other than O – ve are generally readily available.

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III. STORAGE OF BLOOD

Blood and blood products should only be stored in the Blood Bank, and under
the direct care and control of the blood bank technicians.

Blood and blood products that have been issued from the Blood Bank should not
be stored in the ward or theatre refrigerator.

IV. ISSUE AND COLLECTION OF BLOOD AND BLOOD PRODUCTS FROM

THE BLOOD BANK AND DELIVERY TO THE WARD OR OPERATING
THEATRE.

1. Who should collect blood from Blood Bank?

A NURSE or MEDICAL OFFICER is responsible for collecting blood from the

blood bank. A written documentation (the Requisition For Blood Previously
Cross-Matched form – pink in colour) to identify the patient must be presented to
blood bank before blood/ blood product can be issued. Copies of this form are
kept in all wards and theatres.

Under emergency circumstances or in the presence of severe shortages of staff,

the instruction 5 of the Requisition For Blood Previously Cross-Matched form
may be activated.
A copy of the Requisition For Blood Previously Cross-Matched form is appended.

2. Complete the Collection Checklist

The Blood Bank officer who is issuing the blood or blood product must complete
the Collection Checklist before allowing the unit(s) to be removed from the Blood
Bank. Copies of this form are kept at the Blood Bank.
A copy of the Collection Checklist is appended.

3. For Platelet Concentrate

Platelet concentrate should be issued in an insulated carrier that will keep the
temperature at about 20 to 24 degrees Celsius. It should never be placed in the
refrigerator and should be transfused as soon as possible.

V. COMMENCEMENT AND DOCUMENTATION OF TRANSFUSION

1. When to commence transfusion

Once issued by the blood bank into it’s designated insulated container, the
transfusion of whole blood, red cells and thawed fresh frozen plasma should be
commenced within 30 minutes of their removal from refrigeration.

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 If the transfusion cannot be started within this period, they must be returned to
the laboratory so that they can be placed in the proper refrigerator and to be
reissued just before transfusion

2. Pre – Transfusion Checklist

The Pre-transfusion Checklist must be completed first by the officer putting up

the transfusion, before transfusion commences. This will ensure that the
recipient is advised and informed of the procedure, has consented, and is receiving
the correct type and amount of blood and/or blood product at the correct time and
rate. Copies of the Pre-Transfusion Checklist are kept in all wards and theatres.
A copy of the Pre-Transfusion Checklist is appended.

3. Who should put up the Blood or Blood Product unit for transfusion?

It is the responsibility of the treating doctor to put up the first unit of blood or
blood product after completing the Pre-transfusion Checklist.

A Registered Nurse can put up subsequent units after completing the Pre-
transfusion Checklist.

4. The Blood Giving Set

Blood should be transfused through a sterile blood giving set. The set should be
changed every 12hours in order to prevent bacterial growth. The giving set
should also be changed if the drip is running too slow.

Platelet Concentrate must never be transfused using a giving set that has been
previously used for Whole blood or Packed Cells transfusion.

5. Volumes and Rate of Transfusion

Dogmatic directions should not be given concerning volume and rate of

transfusion. The following factors must be considered and the volume and rate of
transfusion be tailored according to the -
i) Age of the patient
ii) Patient’s general condition
iii) State of patient’s circulatory systems
iv) Indication for transfusion.

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 Note:

ii) Infusion of any unit of blood or blood product should not take more than
4 hours because of the risk of infection developing in that unit.

iii) Special paediatrics giving set is available and must be used accordingly.
The Formula for calculation of Volume and Rate for Paediatric Cases is
appended and must be used in all transfusion in children unless instructed
otherwise by the Paediatrician.

iv) Infusion Pumps are not indicated for transfusion for they can damage red
cells.

v) The rate of infusion is also affected by the size of the IV Cannula used
and the choice of vein cannulated for transfusion.

6. Warming of Blood before Transfusion

There is currently no evidence to suggest that warming blood is beneficial to the

patient when infusion is slow.
Cold blood or blood product infused at rates greater than 100mls per minute may
become a contributing factor to cardiac arrest. However, keeping the patient
warm is more important than warming the infused blood.

Special circumstances in which warmed blood is used include:

i) Large volume rapid transfusion
ii) Exchange transfusion in infants
iii) Patient diagnosed with Cold Agglutinins

BLOOD SHOULD ONLY BE WARMED IN THE PROPER BLOOD WARMER

AND NEVER IN A BOWL OF HOT WATER as this can lead to haemolysis of
Red Blood Cells – It is potentially life threatening to transfuse haemolysed blood.

7. Intravenous Medication

Intravenous Drugs and other medications should not be added to the unit of
blood or blood products that is being transfused. However, intravenous
medication may be given directly through the venous access whence the blood or
blood product is being transfused.

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VI. THE CARE AND MONITORING OF TRANSFUSED PATIENTS.

The care of the patient who is receiving a blood or blood product transfusion
should include the following:

1. Advice for Patient

It is the responsibility of the treating Doctor to advise the patient about

symptoms of the Transfusion reactions and what to do (report
immediately to nurse or doctor)
Refer to Appendix 7 and Appendix 10.

2. Visual Observation

Direct visual observation of the patient by the nurse is important.

Transfusion reactions should be considered when assessing a change or
deterioration in the patient’s condition, particularly in the first 15-20
minutes following the start of a unit

3. Monitoring of Vital Signs

The Attending Nurse in all wards and Units is responsible for monitoring
the vital signs of the patient receiving a transfusion of blood and blood
products. For patients under anaesthesia, the attending anaesthetist
undertakes this responsibility.

The patient’s blood pressure, pulse and temperature must be measured at

the start and at end of transfusion.
Vital signs must be checked at 15 minutes and at 30minutes after the start
of each unit of blood or blood component transfusion.
Vital signs must then be checked every 30 minutes until the end of the
transfusion.

Any abnormal reading of vital signs at any check during the transfusion
must be reported immediately to the patient’s physician (Intern or
Registrar)

4. Start and End of Transfusion

The intern or medical officer is required to start the first unit of blood
transfusion and document the starting time. The attending nurse can add
subsequent units for transfusion as per the treatment plan.
The nurse documents the finishing time clearly on the observation notes.

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 5. Routine Observation

Routine observations should be continued even if the patient is

unconscious. Transfusion reactions should be considered if there is a
change or deterioration in the patient’s condition, particularly in the first 15-
20 minutes following the start of a unit.
Hypotension, uncontrolled bleeding due to DIC, hemoglobinuria, or
oligonuria may be the first indication of haemolytic transfusion reaction in
these patients.

VII. UNUSED BLOOD AND BLOOD PRODUCTS

All unused blood and blood products should be returned immediately to the
blood bank for record keeping purposes.

Note:
i) To avoid wastage, the Blood Bank must be informed immediately if cross-
matched blood is not required. This will ‘free-up’ the blood units to be
cross-matched for other requests.

ii) It is normal Blood Bank practice that cross-matched blood and blood
products will not be stored for more than 48hrs. Only requests for placenta
previa cases are exempted.

VIII. ADVERSE EFFECTS OF TRANSFUSION

An Acute Transfusion Reaction occurs in 1 – 2% of transfused patients. Early

recognition and rapid management may save a patient’s life.

All staff members who deal with transfusion of blood and blood products should
familiarize themselves with the symptoms and signs of transfusion reactions and
other adverse effects of transfusion.

The appended Adverse Effects of Transfusion Of Blood And Blood Products can
be used as a guide and reference.

If an Acute Transfusion Reaction is suspected in a patient receiving an infusion

of blood or blood products, the attending doctor and nurse should do the
following:

1. Stop the transfusion immediately.

2. Substitute a saline infusion (Normal Saline or Dextrose Saline) using a

new transfusion set.

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 3. Inform the Blood Bank immediately and do not transfuse any blood or
blood products until the laboratory has rechecked the remains of the unit of
blood.

4. Complete the blue requisition form (coded HE910B – bottom left of the
form) and send it to the laboratory with the remains of the unit of blood or
blood product.
A copy of the Blue form is appended.

5. Send a fresh 10mls of clotted blood (Sterile Tube) and 5mls heparin
sample (Anticoagulant Tube) from the patient, preferably taken from the
opposite arm. A completed Investigation Of A Suspected Transfusion
Reaction Form should accompany these specimens. Copies of this form are
available in all wards and theatres.
A copy of the Investigation Of A Suspected Transfusion Reaction Form is
appended.

6. A sample of the patient’s next urine should be collected and send to the
laboratory for analysis for products of hemolysis.

7. If a case of a reaction is suspected to be due to an infected blood unit, a

blood sample should be collected from the patient for blood culture.

Note:

1. It is important that all specimens mentioned above, that is:

i) 10 mls clotted blood
ii) 5 mls heparinized blood COMPULSORY
iii) Patient’s next urine sample
iv) Blood sample for culture WHERE NECESSARY
Accompanied by the appropriate forms (2 forms, as above) are sent to the
laboratory for a thorough investigation of a transfusion reaction.

3. For the clinical management of Acute Transfusion Reactions, the WHO

Guidelines for the Recognition and Management of Transfusion Reactions is
appended for guidance.

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IX. REPORTING OF ADVERSE EVENTS

1. In all cases of suspected Transfusion Reaction - it is the responsibility of

the medical officer to complete the form for investigation and to provide
the laboratory with all specimens needed for the investigation as soon as
possible.

2. It is the responsibility of the assigned nurse and the supervisor to fill the
UOR if an error in transfusion is detected. Prompt reporting of adverse
events will facilitate early and accurate investigation and prompt remedial
action.

3. The Hospital Blood Transfusion Committee and the Medical Advisory

Committee shall review all adverse events relating to the transfusion of
blood and blood products.

X. TRAINING

It is the responsibility of the Blood Transfusion Committee and the Pathology

Department to ensure that:

1. This guideline is included in the initial orientation of staff in each

department or subdivision.

2. All Staff and stakeholders are trained in the blood transfusion guideline and
procedures

3. Training is undertaken with regular Audits of practice undertaken.

XI. REFERENCE

1. Government of Fiji Islands Pathology Services Users Handbook 2007

2. Government of Fiji Laboratory Users Handbook Pathology Services 1993

3. The Clinical Use of Blood Handbook, WHO Blood Transfusion Safety, Geneva
2003

4. Maximum Blood Order Schedule (MBOS) Lautoka Hospital, undated

memorandum, Dr Dhanna Gounder, Consultant Pathologist, Lautoka Hospital

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Scope and Application This CPG is intended for use by all health care
workers in their daily care of patients who require
Blood transfusion services

Effective Date 2010

Supercedes Policy Number Not applicable

Review Responsibilities The Chairperson of the Pathology CSN will

initiate the review of this guidelines every 3 years
from the date of issue or as required.

Further Information Pathology CSN Chairperson

RESPONSIBILITY:

CPG Owner: National Pathology CSN

CPG Writer: Ministry of Health Date: 2010

Endorsed:
National Medicines & Therapeutic Committee, MOH
Date: 23 November 2010

Endorsed:
National Health Executive Committee, MOH
Date: 25 November 2010

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 13 of 26

 APPENDIX 1
REQUISITION FOR BLOOD AND BLOOD PRODUCTS FOR TRANSFUSION

This guideline is designed for prescribers of blood at all levels of the hospital system, particularly
clinicians and laboratory staff.

It provides a guide to the use of blood and blood products and, in particular, ways of minimizing
unnecessary transfusion.

The appropriate use of blood and blood products means the transfusion of safe blood products
only to treat a condition leading to significant morbidity or mortality that cannot be prevented or
managed effectively by other means.

Clear communication and cooperation between clinical and blood bank staff are essential in
ensuring the safety of blood issued for transfusion.

DEFINITIONS
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 concentrate

Red cell suspension
Plasma
Platelet concentrate

2. Plasma or Platelet

3. Cryoprecipitate, prepared from Fresh Frozen Plasma: rich in factor VIII and Fibrinogen

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 14 of 26

WHOLE BLOOD

A 450 ml whole blood donation contains:

Description:
Up to 510 ml total volume (volume may vary in accordance with local policies)
450 ml donor 63 ml anticoagulant-preservative solution
Haemoglobin approximately 12 g/ml
Haematocrit 35%–45%
No functional platelets
No labile coagulation factors (V and VIII)

Infection risk: Not sterilized, so capable of transmitting any agent present in cells or plasma
which has not been detected by routine screening for transfusion
transmissible infections, including HIV-1 and HIV-2, hepatitis B and C,
other hepatitis viruses, syphilis and malaria

Indications: Red cell replacement in acute blood loss with hypovolaemia

Exchange transfusion
Patients needing red cell transfusions where red concentrates or
suspension is not available

Contraindications: Risk of volume overload in patients with:

Chronic anaemia
Incipient cardiac failure

Administration: Must be ABO and RhD compatible with the recipient

Never add medication to a unit of blood
Complete transfusion within 4 hours of commencement

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RED CELL CONCENTRATE (Packed Red Cells)

Description: 150–200 ml red cells from which most of the plasma has been removed
Haemoglobin approximately 20 g/100 ml (not less than 45 g per unit)
Haematocrit 55%–75%

Infection risk: Same as whole blood

Indications: Replacement of red cells in anaemic patients
Use with crystalloid replacement fluids or colloid solution in acute blood loss

Administration: Same as whole blood

To improve transfusion flow, normal saline (50–100 ml) may be added
using a Y-pattern infusion set.

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PLATELET CONCENTRATES
(PREPARED FROM WHOLE BLOOD DONATION)

Description: Single donor unit in a volume of 50–60 ml of plasma should contain:

At least 55 x 10^9 platelets
<1.2 x 10^9 red cells
<0.12 x 10^9 leucocytes

Infection risk: Same as whole blood, but a normal adult dose involves between 4 and 6
donor exposures
Bacterial contamination affects about 1% of pooled units

Indications: Treatment of bleeding due to:

-Thrombocytopenia
-Platelet function defects
Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure

Contraindications: Not generally indicated for prophylaxis of bleeding in surgical patients,

unless known to have significant pre-operative platelet deficiency

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Not indicated in:
-Idiopathic autoimmune thrombocytopenic purpura (ITP)
- Thrombotic thrombocytopenic purpura (TTP)
-Untreated disseminated intravascular coagulation (DIC)
-Thrombocytopenia associated with septicemia, until treatment has
commenced or in cases of hypersplenism

Dosage: 1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6

single donor units containing at least 240 x 109 platelets should raise the
platelet count by 20–40 x 10^9/L

Increment will be less if there is:

-Splenomegaly
-Disseminated intravascular coagulation
-septicaemia

Administration: After pooling, platelet concentrates should be infused as soon as possible,

generally within 4 hours, because of the risk of bacterial proliferation.

Must not be refrigerated before infusion as this reduces platelet function.

4–6 units of platelet concentrates (which may be supplied pooled) should be
infused through a fresh standard blood administration set.
Special platelet infusion sets are not required.
Should be infused over a period of about 30 minutes.
Do not give platelet concentrates prepared from RhD positive donors to an
RhD negative female with childbearing potential.
Give platelet concentrates that are ABO compatible, whenever possible

Complications: Febrile non-haemolytic and allergic urticarial reactions are not

uncommon, especially in patients receiving multiple transfusions

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FRESH FROZEN PLASMA

Description: Pack containing the plasma separated from one whole blood donation within
6 hours of collection and then rapidly frozen to –25C or cold er
Contains normal plasma levels of stable clotting factors, albumin and
Immunoglobulin
Factor VIII level at least 70% of normal fresh plasma level

Unit of issue: Usual volume of pack is 200–300 ml

Smaller volume packs may be available for children

Infection risk: If untreated, same as whole blood

Very low risk if treated with methylene blue/ultraviolet light inactivation

Indications: Replacement of multiple coagulation factor deficiencies: e.g.

- Liver disease
- Warfarin (anticoagulant) overdose
- Depletion of coagulation factors in patients receiving large volume transfusions

Disseminated intravascular coagulation (DIC)

Thrombotic thrombocytopenic purpura (TTP)

Precautions: Acute allergic reactions are not uncommon, especially with rapid infusions
Severe life-threatening anaphylactic reactions occasionally occur
Hypovolaemia alone is not an indication for use

Dosage: Initial dose of 15 ml/kg

Administration: Must normally be ABO compatible to avoid risk of haemolysis in recipient

No compatibility testing required
Infuse using a standard blood administration set as soon as possible
after thawing.
Labile coagulation factors rapidly degrade; use within 6 hours of thawing

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CRYOPRECIPITATE

Description: Prepared from fresh frozen plasma by collecting the precipitate formed
during controlled thawing at +4C an d resu sp en d in g it in 10–20 ml
plasma
Contains about half of the Factor VIII and fibrinogen in the donated
Whole blood: e.g. Factor VIII: 80–100 iu/ pack; fibrinogen: 150–300
mg/pack

Infection risk: As for plasma, but a normal adult dose involves at least 6 donor exposures

Indications: As an alternative to Factor VIII concentrate in the treatment of inherited

deficiencies of:
- Von Willebrand Factor (von Willebrand’s disease)
- Factor VIII (haemophilia A)
- Factor XIII
As a source of fibrinogen in acquired coagulopathies:
E.g. disseminated intravascular coagulation (DIC)

Administration: If possible, use ABO-compatible product

No compatibility testing required
After thawing, infuse as soon as possible through a standard blood
administration set
Must be infused within 6 hours of thawing

References

Australian National Health and Medical Research Council (NHMRC) Practice Guidelines

Australasian Society of Blood Transfusion (ASBT)

WHO The Clinical Use of Blood Handbook

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 20 of 26

Scope and Application This CPG is intended for use by all health care
workers in their daily care of patients who require
Blood transfusion services

Effective Date 2010

Supercedes Policy Number Not applicable

Review Responsibilities The Chairperson of the Pathology CSN will

initiate the review of this guidelines every 3 years
from the date of issue or as required.

Further Information Pathology CSN Chairperson

RESPONSIBILITY:

CPG Owner: National Pathology CSN

CPG Writer: Ministry of Health Date: 2010

Endorsed:
National Medicines & Therapeutic Committee, MOH
Date: 23 November 2010

Endorsed:
National Health Executive Committee, MOH
Date: 25 November 2010

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 21 of 26

 APPENDIX 2
Guideline for the Recognition and Management of Acute Transfusion
Reactions.

GUIDELINES FOR THE RECOGNITION AND MANAGEMENT OF

ACUTE TRANSFUSION REACTIONS
(The Clinical Use of Blood Handbook, WHO 2003)

CATEGORY 1: MILD REACTIONS

Signs Symptoms Possible Cause

• Localized cutaneous • Pruritis (itching) • Hypersensitivity
Reactions: (mild)
- Urticaria
- Rash

IMMEDIATE MANAGEMENT

1. Slow the transfusion

2. Administer antihistamine IM (e.g. Chlorpheniramine 0.1mg/kg or equivalent)

3. If no clinical improvement within 30 minutes or if signs and symptoms worsen,

treat as CATEGORY 2.

CATEGORY 2: MODERATELY SEVERE REACTIONS

Signs Symptoms Possible Cause

• Flushing • Anxiety • Hypersensitivity
• Urticaria • Pruritis (moderate-severe)
• Rigors • Palpitations • Febrile non-haemolytic
• Fever • Mild dyspnoea transfusion reactions:
• Restlessness • Headache ° Antibodies to white
• Tachycardia blood cells, platelets
° Antibodies to proteins
including IgA
• Possible contamination
with pyrogens and/or
Bacteria

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IMMEDIATE MANAGEMENT

1. Stop the transfusion. Replace the infusion set and keep IV line open with normal saline.

2. Notify the doctor responsible for the patient and the blood bank immediately.
3. Send blood unit, with infusion set, freshly collected urine and new blood samples (1 clotted
and 1 anticoagulated) from vein opposite infusion site with appropriate request form to
blood bank for laboratory investigations.

4. Administer antihistamine IM (i.e. chlorpheniramine 0.1mg/kg or equivalent) and oral or

rectal antipyretic (e.g. Paracetamol 10mg/kg: 500mg – 1 g in adults). Avoid aspirin in
thrombocytopenic patients.

5. Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g.

bronchospasm, stridor).

6. Collect urine for next 24 hours for evidence of haemolysis and send to laboratory.

7. If clinical improvement, restart transfusion slowly with new blood unit and observe
carefully.

8. If no clinical improvement within 15 minutes or if signs and symptoms worsen, treat

as CATEGORY 3.

CATEGORY 3 LIFE THREATENING REACTIONS

Signs Symptoms Possible Causes

• Rigors • Anxiety • Acute intravascular
• Fever • Chest pain haemolysis
• Restlessness • Pain near infusion site • Bacterial contamination
• Hypotension (fall of 20% in • Respiratory distress/ • Fluid overload
Systolic BP) shortness of breath
• Tachycardia (rise of 20% in • Loin/back pain • Anaphylaxis
Heart rate).
• Haemoglobinuria -red urine • Headache • Transfusion associated
• Unexplained bleeding -DIC • Dyspnoea acute lung injury (TRALI)

NOTE
1. If an acute transfusion reaction occurs, first check the blood pack labels and the patient’s identity. If there is
any discrepancy, stop the transfusion immediately and consult the blood bank.

2. In an unconscious or anaesthetized patient, hypotension and uncontrolled bleeding may

be the only signs of an incompatible transfusion.

3. In a conscious patient, undergoing a severe haemolytic transfusion reaction, signs and

symptoms may appear very quickly – within minutes of infusing only 5-10 ml of blood.
Close observation at the start of the infusion of each unit is essential.

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IMMEDIATE MANAGEMENT

1. Stop the transfusion. Replace the infusion set and keep IV line open with normal saline.

2. Infuse normal saline (initially 20-30 ml/kg) to maintain systolic BP. If hypotensive, give over
5 minutes and elevate patient’s legs.

3. Maintain airway and give high flow oxygen by mask.

4. Give adrenalin 1mg (Adults) or 0.01ml/kg of 1/1000 (maximum 0.5ml), into lateral thigh
for paediatrics by slow intramuscular injection.

5. Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g.

Broncospasm, stridor)

6. Give diuretic, e.g. Frusemide 1mg/kg IV or equivalent.

7. Notify the doctor responsible for patient and blood bank immediately.

8. Send blood unit with infusion set, fresh urine sample and new blood samples (1 clotted
and 1 anticoagulated) from vein opposite infusion site with appropriate request form to
blood bank for investigations.

9. Check a fresh urine specimen visually for signs of haemoglobinuria.

10. Start a 24-hour urine collection and fluid balance chart and record all intake and output.
Maintain fluid balance.

11. Assess for bleeding from puncture sites or wounds. If there is clinical or laboratory
evidence of DIC, give platelets (adult: 5-6 units) and either cryoprecipitate (adult: 12 units)
or fresh frozen plasma (adult: 3 units).

12. Reassess. If hypotensive:

• Give further saline 20-30 ml/kg over 5 minutes
• Give inotrope, if available

13. If urine output falling or laboratory evidence of acute renal failure (rising K+, urea,
creatinine):
• Maintain fluid balance accurately
• Give further frusemide
• Consider dopamine infusion, if available
• Seek expert help: the patient may need renal dialysis.

14. If bacteraemia is suspected (rigors, fever, collapse, no evidence of a haemolytic reaction),

start broad-spectrum antibiotics IV.

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 24 of 26

 Type of Drug EFFECTS EXAMPLES
Name Route/Dose
NOTES
Intravenous Expands blood Normal saline If patient Avoid colloid
replacement fluid volume hypotensive, 20- solutions
30ml/kg over 5
minutes

Antipyretic Reduces fever Paracetamol Oral or rectal Avoid aspirin

and inflammatory 10ml/kg containing
response products if low
platelet count
Antihistamine Inhibits histamine Chlorpheniramine IM or IV
mediated 0.1mg/kg
responses

Bronchodilator Inhibits immune Adrenaline 0.01mg/kg (as Dose may be

mediated 1:1000 solution) repeated every
bronchospasm by slow IM 10 minutes,
injection according to BP
and pulse until
improvement
Consider By nebuliser
Salbutamol
5mg/kg
Aminophylline
Inotrope Increases Dopamine IV Infusion Low doses
myocardial 1ug/kg/minute induce
contractility vasodilation and
improve renal
perfusion

Dobutamine IV Infusion 1-10 Doses above 5

ug/kg/minute ug/kg/minute
cause
vasoconstriction
and worsen heart
failure
Diuretic Inhibits fluid Frusemide Slow IV injection
reabsorption 1mg/kg
from ascending
loop of Henle

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 25 of 26

Scope and Application This CPG is intended for use by all health care
workers in their daily care of patients who require
Blood transfusion services

Effective Date 2010

Supercedes Policy Number Not applicable

Review Responsibilities The Chairperson of the Pathology CSN will

initiate the review of this guidelines every 3 years
from the date of issue or as required.

Further Information Pathology CSN Chairperson

RESPONSIBILITY:

CPG Owner: National Pathology CSN

CPG Writer: Ministry of Health Date: 2010

Endorsed:
National Medicines & Therapeutic Committee, MOH
Date: 23 November 2010

Endorsed:
National Health Executive Committee, MOH
Date: 25 November 2010

© MOH_ National Blood Transfusion Policy -Pathology CSN_2010 Page 26 of 26