What are the key components of a safe and effective blood transfusion protocol?

Key Components of a Safe and Effective Blood Transfusion Protocol

A comprehensive blood transfusion protocol must include patient identification verification, appropriate blood component selection, proper administration techniques, monitoring for adverse reactions, and documentation of the entire process to ensure patient safety and optimal outcomes. 1

Patient Identification and Consent

• Every institution should have a clear policy for patient identification before transfusion, including procedures for unidentified patients in emergency situations 1
• Informed consent should be obtained and documented before the procedure whenever possible, discussing anticipated transfusion needs, alternatives, and potential risks 2
• For unidentified patients, attach identification stating "unknown male/female" with a unique identification number, and ensure blood samples sent to the laboratory contain these exact details 1
• If a patient's identity becomes known during treatment, new identification must be attached and a new transfusion sample collected with the correct patient details 1

Pre-Transfusion Assessment

• All patients should have their hemoglobin concentration measured before listing for major elective surgery 1
• Patients with anemia (Hb < 130 g/L for men, < 120 g/L for women) should be investigated and treated appropriately before elective surgery 1
• In non-bleeding patients, use a restrictive transfusion strategy with a hemoglobin threshold of 70 g/L as a general guide for red cell transfusion 1
• Consider a higher threshold (80 g/L) for patients with ischemic heart disease, including acute coronary syndrome and after cardiac surgery 1

Blood Component Administration

• Red blood cells should be transfused one unit at a time with hemoglobin checked before each unit, unless there is ongoing bleeding or a large deficit 1
• Use only blood component administration sets that are compatible with the infusion device being used 1
• Administration sets used with infusion devices should incorporate an integral mesh filter (170-200 μm) 1
• Perform pre-administration checks including verification of the device and device settings 1

Blood Warming Requirements

• In all adults undergoing elective or emergency surgery under general or regional anesthesia, intravenous fluids (500 mL or more) and blood components should be warmed to 37°C 1, 3
• Blood should only be warmed using approved, specifically designed and regularly maintained blood warming equipment with a visible thermometer and audible warning 1, 3
• Never warm blood using improvisations such as putting the pack in warm water, in a microwave, or on a radiator 1
• The greatest benefit comes from controlled warming of red cells (stored at 4°C) rather than platelets or thawed plasma 3

Monitoring During Transfusion

• Clinical observations should include heart rate, blood pressure, temperature, and respiratory rate at minimum pre-transfusion, at the end of transfusion, and 15 minutes after transfusion 1
• If signs of a transfusion reaction occur (tachycardia, rash, breathlessness, hypotension, fever), stop the transfusion immediately and contact the laboratory 1
• Management of reactions may include antihistamines, steroids, or intramuscular/intravenous adrenaline if life-threatening 1
• Monitor for signs of transfusion-associated circulatory overload (TACO), particularly in older, non-bleeding patients with comorbidities 1

Major Hemorrhage Management

• Every institution should have a massive transfusion protocol that is regularly audited and reviewed 1
• Group O red cells should be readily available in clinical areas for life-threatening hemorrhage, with group-specific red cells available within 15-20 minutes 1
• During major hemorrhage due to trauma and obstetrics, consider transfusing red cells and FFP in preference to other intravenous fluids 1
• For patients with ongoing bleeding, monitor coagulation, fibrinogen, and platelet counts using point-of-care and/or laboratory tests 1
• Consider transfusing FFP if fibrinogen < 1.5 g/L or INR > 1.5, cryoprecipitate if fibrinogen < 1.5 g/L, and platelets if platelet count < 75 × 10^9/L 1
• Consider using tranexamic acid in all non-obstetric patients where blood loss > 500 mL is possible and in traumatic and obstetric major hemorrhage 1

Documentation and Reporting

• Document all transfusion procedures in the patient's medical record, including the indication for transfusion, products administered, and any adverse reactions 2
• Report adverse transfusion reactions according to local protocols and national hemovigilance systems 1
• Inform the patient's general practitioner that they have received blood components 2
• When transferring patients between facilities, ensure effective communication between blood transfusion laboratories according to regional policy 1

Special Considerations

• Blood components should be prescribed for small children by volume rather than number of units 1
• For patients being transferred, blood components must be transported in appropriate storage containers to maintain their integrity 1
• Consider patient blood management strategies to reduce transfusion needs, including treating anemia preoperatively, optimizing perioperative hemostasis, and using blood recovery systems 4
• Implement restrictive transfusion practices with appropriate clinical decision support via electronic medical records to reduce inappropriate blood transfusions 5

By implementing these key components, healthcare facilities can ensure safe and effective blood transfusion practices that minimize risks while maximizing patient benefits.