Blood Safety: The Right Blood Product to the Right Patient at the Right Time

by Dr. Rita Govender, Haematologist

PATHCHAT Edition No. 7
Please contact your local Ampath pathologist for more information.

The Importance of Safe Blood Transfusion

The decision to transfuse requires an evaluation of the risk-benefit ratio for each patient and must include documented informed consent.

🔹 Key factors in minimizing transfusion risks:

1. Strict donor selection processes.
2. Rigorous blood testing procedures.
3. Careful bedside transfusion practices.

Haemovigilance programs (local & international) show that incorrect patient identification is a leading cause of transfusion-related morbidity.

The Three Pillars of Blood Safety

1. Donor Selection

• Only voluntary, non-remunerated donors are accepted.
• Donors complete a detailed medical and behavioral questionnaire to assess their risk for HIV and transfusion-transmissible infections.
• Donors also have an option to self-exclude if they believe their blood may not be safe.

2. Testing of Donors and Blood Units

• Routine testing includes:
  • Serology for Hepatitis B surface antigen (HBsAg), Hepatitis C antibodies, HIV-1 & HIV-2 antibodies, and Syphilis.
  • Nucleic Acid Testing (NAT) (PCR-based) for HIV, HBV, and HCV.
• Blood remains quarantined until all tests return negative.

🔹 What happens if a donation tests positive?

• The donor is notified, counseled, and permanently deferred from donating blood.
• Look-back program: The South African National Blood Service (SANBS) traces recipients of previous donations from the affected donor.

✅ Since the implementation of Nucleic Acid Testing (NAT) in 2005, no documented cases of HIV transmission via blood transfusion have occurred.

3. Clinician’s Role in Safe Transfusion

Before transfusion, if the patient is haemodynamically stable, clinicians should:

1️⃣ Perform Clinical & Laboratory Evaluation:

• Identify underlying causes of cytopenias and bleeding disorders.
• Consult a haematologist for peripheral blood smear analysis or coagulopathy investigations.

2️⃣ Consider Alternatives to Transfusion:

• Pharmacological interventions:
  • Haematinic replacement
  • Pro-haemostatic agents (e.g., Cyclokapron, DDAVP)
• Blood conservation strategies:
  • Pre-operative autologous donation (for elective surgeries).
  • Acute normovolemic haemodilution.
  • Cell salvage techniques.

3️⃣ Ensure Proper Transfusion Protocols:

• Choose the correct blood product for the clinical situation.
• Obtain and document informed consent.
• Correctly identify the patient and label crossmatch samples at the bedside.

Bedside Transfusion Protocol

At least two medical personnel (doctor and registered nurse, or two nurses) must:

✅ Verify patient details (ID, name, blood group, expiry date).
✅ Confirm the prescription and check for previous transfusion history.
✅ Inspect the blood unit for leaks, clots, discoloration, or abnormalities (any irregularity precludes transfusion).

Monitoring During Transfusion

💉 Aseptic technique is mandatory during cannulation to prevent bacterial contamination.

Vital Sign Monitoring

1. Baseline vitals (pulse, BP, respiratory rate, temperature, urine output in critically ill patients).
2. Monitor every 15 minutes during the transfusion.
3. Close observation for the first 30 minutes at a slow infusion rate (2 ml/min).
4. Transfusion rates depend on clinical indication:
   • Red cell products: 2 to 5 ml/min (must be completed within 6 hours).
   • Platelets: Administered over 15-20 minutes.

Adverse Transfusion Reactions

🔴 Signs of a reaction:

• Change in BP, temperature
• Chest/back pain
• Skin reactions

🚨 Immediate Actions:

1. Stop the transfusion immediately.
2. Change IV drip set and maintain vein patency with normal saline.
3. Record vital signs & initiate emergency management (e.g., for anaphylaxis).
4. Repeat all bedside checks (patient ID, blood unit verification).
5. Contact the transfusion service and complete legal documentation.
6. Submit samples for investigation:
   • Repeat crossmatch
   • Liver function tests (LFTs)
   • Blood cultures (if bacterial contamination is suspected)
   • Urine sample
   • Return the blood unit & administration set for analysis

Key Guidelines for Blood Transfusion

🩸 Blood Administration Sets
✔ Use a standard recipient set for red cell products.
✔ Use a platelet-specific giving set (smaller filter surface to minimize loss).

🚫 What NOT to Do:
❌ Do not use bedside leucodepletion filters on pre-leucodepleted units (causes unnecessary cost & 10% red cell loss).
❌ Microaggregate filters are not required due to modern processing.
❌ Do not refrigerate platelets before transfusion.
❌ Do not add medication or fluids to blood products.

✅ Approved Fluids for Use with Blood:

• Normal saline (0.9%)
• 4% Albumin
• Plasma protein fractions
• ABO-compatible plasma

Special Considerations for Transfusion

🔹 Paediatric Red Cell Transfusions:

• Minimize donor exposure → Request a limited donor exposure program (LDEP) from the blood bank.

🔹 Blood Warming:

• Use ONLY approved blood-warming devices if:
  • Massive transfusion > 50 ml/kg/hr
  • Neonatal exchange transfusion
  • Cold agglutinins requiring warming above 30°C

🔹 Blood Bag Retention:

• Empty blood bags must be stored for 48 hours post-transfusion in compliance with regulations.

References & Additional Resources

📖 South African Standards for Blood Transfusion Practice
📖 Clinical Guidelines for Use of Blood Products in South Africa (4th Edition)
📖 Leucocyte Depletion Guidelines – Blood Transfusion Services of South Africa
📖 SAMJ: Blood Conservation & Bloodless Surgery (May 2006, Vol 96:5)
📖 Transfusion (2004): Overview of Blood Conservation, 44:1S-3S

🌍 Useful Websites:
🔗 SANBS (South African National Blood Service)
🔗 British Committee for Standards in Haematology – Blood Transfusion Taskforce