1. Informed Consent
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Patients /families must be given information regarding the risks/benefits and alternatives, including the option of no transfusion. |
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It is recommended that the following information is documented in the case notes. ● The discussion with the patient. (Details of the information provided to the patient). ● Reason for transfusion (clinical and laboratory data). ● The administration of the transfusion and any complications. ● The clinical outcome. ● Consent to proceed. ● Wherever consent is not possible i.e., in an emergency or for an unconscious patient, the decision to treat must be documented in the patient’s medical notes detailing why the transfusion is judged to be in the best interests of the patient. |
2. The request form for blood transfusion to blood bank must be completed in full and include
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Full name – surname and forename. |
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Hospital number of the patient. |
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Date of birth/age of patient. |
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Patients’ location. |
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Primary Consultant/ Physician name. |
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Number and type of blood products required. |
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Date and time required. |
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Patient’s diagnosis / clinical details (include pregnancy status). |
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Reason for the request (clinical indication) including most recent hemoglobin and or platelet count. |
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Any special requirements (e.g., Irradiated, HLA matched, CMV negative). |
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Use restrictive transfusion strategy in the critically ill non bleeding patients. |
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Hb <7gm/dL is usual trigger for transfusion. |
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Hb 7- 9gm/dL should be transfused if evidence of ischemia or impaired oxygen delivery (acute coronary syndrome, neurotrauma or neurological diseases). |
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Hb > 9gm/dL- transfusion not required. |
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Actively bleeding critically ill patients require lower threshold to transfuse. |
4. Transfusion triggers of platelets
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Patients with platelet counts <10000/mm3 with no risk factors of serious bleeding. |
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Patients with platelet counts <20000 /mm3 with additional risk factors of serious bleeding. (e.g., uremia, liver disease, antiplatelet drugs) and before minor interventions in ICU (central line insertion, paracentesis, thoracentesis, diagnostic bronchoscopy). |
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Platelet count of <50000 /mm3 in patients with active bleeding, major surgery or intervention. |
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Platelet >100000/mm3 recommended for any ophthalmic or central nervous system surgeries. |
5. Transfusion triggers of Fresh Frozen Plasma
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Plasma transfusions in non-bleeding patients is not advised. |
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Presence of laboratory proven coagulopathy with active bleeding (INR >1.5-2). |
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Emergency reversal of Warfarin effect for urgent surgery or ongoing active bleeding. |
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Liver disease with coagulopathy in the presence of active bleeding or needing an intervention. |
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Transfuse plasma as part of massive transfusion protocol in the ratio of 1:1:1 (one unit plasma and one unit of platelets for each unit of RBCs). |
Consider using four factor Prothrombin Complex Concentrate (PCC) when indicated.
6. Volume, administration and expected effect
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Component |
Volume (one unit) |
Duration of administration |
Expected Effect |
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Whole blood |
300ml |
2-4 hrs |
Hb increase by 1gm/dL. |
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Packed RBC |
200ml |
2-4 hrs |
Hb increase by 1gm/dL. |
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Platelet rich plasma |
40-70 ml |
15 mins |
Platelet increase by 5,000-7,500/uL. |
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Random donor Platelet concentrate (PC) |
50-70 ml |
15 mins |
Platelet increase by 5,000-10,000 /uL. |
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Single donor platelet concentrates |
200-300 ml |
30 mins |
Platelet increase by 20,000-40,000 /uL |
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Fresh frozen plasma |
200-250 ml |
15-30 mins |
10 to 20 mL/kg raise factor levels by 20% |
7. Monitoring And Infusion
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Obtain baseline temperature/blood pressure/respiratory rate/heart rate/ oxygen saturation just before infusion starts. |
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Confirm blood product received matches with doctors’ orders. |
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Confirm donor ABO/RH group. |
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Visualize blood product to confirm expiratory date/leak/color and consistency of the product. |
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Transfusion should commence within 15 minutes of receiving blood. |
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Initial transfusion rate 50 ml/hr. for first 15 minutes, then repeat vital signs, and document. |
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Blood product bag should NOT be hanged for MORE THAN 4 HOURS. |
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During transfusion, monitor and document vital signs hourly and as required. |
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Fill the Blood and blood products transfusion checklist. |
8. Transfusion Reactions
8.1. Watch Out For
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Fever. |
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Dyspnea: Increased shortness of breath, decreased SpO2. |
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Urticaria & other allergic reactions - minor allergic reaction to severe anaphylaxis. |
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Hypotension, Hemolysis. |
8.2. If any of the above
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STOP Blood / Blood Product Transfusion AND disconnect the tubing. |
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Inform On Duty Doctor. |
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Ensure Adequate IV Access / Start IV Normal saline. |
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Check vital signs every 15 minutes until stable. |
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Send the Blood and tubing to Blood Bank for Cross Matching and other investigations. |
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The volume and color of any urine passed should be recorded in the patient’s notes. |
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Treat anaphylaxis and anaphylactic shock as standard guideline. |
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Document the transfusion reaction in the clinical note. |
Further readings:
1. Hébert, P. C., Wells, G., Blajchman, M. A., Marshall, J., Martin, C., Pagliarello, G., ... & Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care Trials Group. (1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. New England Journal of Medicine, 340(6), 409-417.
2. Holst, L. B., Haase, N., Wetterslev, J., Wernerman, J., Guttormsen, A. B., Karlsson, S., ... & Perner, A. (2014). Lower versus higher hemoglobin threshold for transfusion in septic shock. New England Journal of Medicine, 371(15), 1381-1391.
3. Holcomb, J. B., Tilley, B. C., Baraniuk, S., Fox, E. E., Wade, C. E., Podbielski, J. M., ... & PROPPR Study Group. (2015). Transfusion of plasma, platelets, and red blood cells in a 1: 1: 1 vs a 1: 1: 2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. Jama, 313(5), 471-482.
4. Vlaar, A. P., Oczkowski, S., de Bruin, S., Wijnberge, M., Antonelli, M., Aubron, C., ... & Cecconi, M. (2020). Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Medicine, 46, 673-696.
5. Karanth, S. (2019). Transfusion Triggers for Platelets and Other Blood Products. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 23(Suppl 3), S189.
