Legal Requirements

• Patient Information:
  • Inform the patient about complications, necessity, risks of omission, and alternatives (e.g., preoperative autologous blood donation).
• Patient Consent:
  • No transfusion without the consent of a competent and conscious patient.
  • For minors, involve the guardianship court if necessary (e.g., parents who are Jehovah’s Witnesses refusing blood or blood components).
  • For unconscious patients:
    • Consider the presumed or previously documented wishes (e.g., advance directive).
    • Relatives do not have decision-making rights (exception: legal guardians for minors).
  • For incapacitated patients:
    • Consent must be obtained from the legal guardian or authorized representative.
    • In the absence of a guardian, follow the presumed or previously documented wishes (e.g., advance directive).
    • In uncertain cases, involve the guardianship court.
• Documentation:
  • Patient information and consent must be thoroughly documented.
• Compliance with Legal Regulations for Blood Transfusion:
  • Blood group determination, compatibility testing, and bedside testing are mandatory.

Erythrocyte Transfusion

• Important Note:
  • Erythrocyte transfusion is a medical procedure. Collect patient blood early for necessary serological tests and preparation of units.
• Preparations:
• Erythrocyte Concentrate (EC):
  • Derived from 500 ml of whole blood through centrifugation.
  • High erythrocyte content (hematocrit 70–80%) with minimal plasma, leukocytes, and platelets.
  • Stored at +4°C for 3–5 weeks, depending on the stabilizer.
  • Indications: Acute and chronic anemia.
  • Rule of Thumb: One EC increases hemoglobin (Hb) by approximately 1 g/dl.
• Special Preparations:
• Leukocyte-Depleted EC:
  • Leukocytes and platelets reduced by 99%, minimizing immunization or CMV transmission risk.
  • Used in planned organ transplantation, immunosuppression, or regular erythrocyte substitution.
• Washed EC:
  • Plasma mostly removed; used immediately after preparation.
  • Indicated for plasma intolerance or selective IgA deficiency.
• Fresh Blood:
  • Preserved for up to 72 hours, containing functional blood components.
  • Used in exchange transfusions, e.g., severe hemolysis.
• Whole Blood:
  • Contains cellular components and plasma in physiological ratios but rarely used today.
• Procedure:
  • Ensure patient and unit identity (name, date of birth) at all stages.
  • Perform serological tests: blood group, Rh factor, cross-matching, and irregular antibody screening.
  • For further transfusions, repeat cross-matching and antibody screening every three days.
• Emergency Transfusions:
  • In life-threatening situations, uncross-matched blood may be used. Alternatives:
    • Unknown blood group: O Rh-negative EC.
    • Blood group A: O EC.
    • Blood group B: O EC.
    • Blood group AB: A, B, or O EC.

Bedside Testing

• Procedure:
  • Conducted by the transfusing physician or under their supervision.
  • Performed immediately before transfusion at the patient’s bedside.
  • Test procedure:
    • Use Anti-A (blue) and Anti-B (yellow) test sera.
    • Add a blood sample and observe for agglutination, indicating blood group.
  • Document results meticulously.
• Caution:
  • Failure to perform, document, or preserve bedside test results constitutes malpractice.

Transfusion Monitoring

• Initial Monitoring:
  • Observe the patient during the first minutes of transfusion.
  • Frequent vital sign checks (e.g., blood pressure, pulse) every 10 minutes during the first half hour.
  • Transfusion duration: 1–2 hours (unless an emergency).
• Post-Transfusion Handling:
  • Retain empty blood bags and transfusion equipment under sterile conditions for 24 hours to investigate potential reactions.

Complications

• Non-Hemolytic Reaction:
  • Cause: Anti-leukocyte antibodies.
  • Symptoms: Fever, chills, nausea, headache, hypotension.
  • Management: Stop transfusion, maintain venous access, symptomatic treatment.
• Hemolytic Reaction:
  • Cause: Anti-erythrocyte antibodies (e.g., ABO incompatibility).
  • Symptoms: Severe shock, coagulation disorders, circulatory and organ failure.
  • Management: Stop transfusion immediately, secure the transfusion set and unit for lab analysis, initiate shock treatment.
• Bacterial Contamination:
  • Cause: Endotoxin-producing gram-negative bacteria.
  • Symptoms: Fever, chills, rapid shock onset.
  • Management: Stop transfusion, initiate shock treatment, start antibiotics.
• Infections:
  • Rare due to donor screening (e.g., Hepatitis C: 1:20,000; Hepatitis B: 1:50,000; HIV: 1:500,000).
• Volume Overload:
  • Risk in rapid or excessive transfusion in patients with heart or kidney insufficiency.

Massive Transfusions

• Definition: Replacement of more than 1.5 times total blood volume within 24 hours.
• Complications:
  • Hypothermia: Warm blood units to max 37°C.
  • Coagulation disorders: Administer fresh frozen plasma (FFP).
  • Hypocalcemia: Calcium supplementation.
  • Hyperkalemia: Initiate corrective measures.
  • Metabolic acidosis: Administer sodium bicarbonate.
  • Acute respiratory distress syndrome (ARDS).
• Recommendation:
  • Intensive monitoring of blood counts, coagulation, electrolytes, and acid-base balance after massive transfusion.

Platelet Transfusion

• Indications:
  • Platelet count <10,000/μl or <20,000/μl with bleeding.
  • Acute bleeding with platelet count <30,000/μl.
  • Preoperative prophylaxis or diagnostic punctures with platelet count <50,000/μl.
  • Preparations:
• Single-Donor Platelet Concentrates: 0.5 × 10¹¹ platelets/50 ml plasma.
• Pooled Platelet Concentrates: From 4–6 ABO-compatible donors (increased infection risk).
• Complications:
  • Infections, allergic reactions, alloimmunization in repeated transfusions.
• Recommendations:
  • For recurrent platelet transfusion, perform HLA typing for compatible donors.

Fresh Frozen Plasma (FFP) Substitution

• Indications:
• Massive transfusion (e.g., 1 FFP unit for every 2 EC units after the 5th unit).
• Coagulopathy, bleeding tendency due to clotting disorders.
• Procedure:
• Ensure ABO compatibility.
• Thaw using specialized blood warmers and transfuse immediately.
• Complications:
• Infections and transfusion reactions.

Specialized Coagulation Substitution

• Prothrombin Complex (PPSB):
• Replaces factors II, VII, IX, and X.
• Dosage: 1 IU/kg body weight per desired Quick value increase.
• Antithrombin III (AT III):
• Used for AT III deficiency.
• Dosage: 1 IU/kg body weight per desired AT III increase.
• Single Factor Concentrates:
• Indicated for congenital clotting disorders or specific needs.

Human Albumin Substitution

• Indications:
• Volume replacement, especially in plasma loss (e.g., severe bleeding, burns).
• Hypoalbuminemia.
• Precautions:
• Use cautiously in heart failure.
• Complications:
• Allergic reactions (rare) and volume overload in heart or kidney failure.