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• Properties and functions of blood
• Plasma proteins
• Bone marrow
• Red blood cells
• White blood cells
blood and blood transfusions 3
• Blood is considered as river of life, fluid of life, fluid
of growth, fluid of health.
• Average human has 5 liters of blood i.e 8% of total
• It is a transporting fluid.
• It carries vital substances to all parts of body.
4blood and blood transfusions
Properties Of Blood
• Color range
• Oxygen-rich blood is scarlet
red bright crimson
• Oxygen-poor blood is purple
• Red color comes from the
several million red cells, present
• pH must remain between 7.35–
• Temp 38 c or 100.4 F
5blood and blood transfusions
• Blood is 5 times more viscous
• Blood is a specialized type of
connective tissue in which living
blood cells, (formed elements),
are suspended in a non living fluid
matrix called plasma.
• Cellular Part (Formed
• Non cellular part (Plasma)
6blood and blood transfusions
Functions of blood
Blood performs a number of functions.
blood and blood transfusions
• Maintainance Functions
• Buffering Functions
• Preventing blood loss
• Defensive function
9blood and blood transfusions
• Plasma is the fluid portion of the blood. It constitutes about
5% of the body weight.
• If blood is allowed to clot, then a clear, straw colored fluid
oozes out. This is the serum .
• Serum is similar to plasma, except that serum does not
have clotting factors.
• SERUM = PLASMA - FIBRINOGEN
blood and blood transfusions 10
• It contain all the vital substances.
• These vital substances include digested
food, salts, hormones, enzymes,
substances essential for clotting of blood,
and antibodies , which are important for
blood and blood transfusions 11
Separation Of Plasma Proteins
• Precipitation method
• Salting out method
• Electrophoretic method
• cohn’s fractional precipitation method
• Ultracentrifugation method
• gel filtration chromatography
• Immunoelectrophoretic method
blood and blood transfusions 13
• Molecular weight Albumin- 69,000
• Oncotic pressure- about 25 mm Hg
• Specific gravity- 1.026
• Buffer capacity- 1/6 of total buffering action
• In embryo – synthesized by mesenchymal
• In adults – mainly from reticuloendothelial
cells of liver
blood and blood transfusions 14
Functions of plasma
• Helps in transport of substances in the
• Maintains colloid osmotic pressure of
• Causes blood clotting because it contains
the fibrinogen and prothrombin
• Stores proteins for supply in needs
• Helps provides viscosity to blood
• Contains antibodies and antitoxins
15blood and blood transfusions
• The bone marrow is present in the bone cavities.
• It can be considered as one of the largest organs in the
body, and also one of the most active.
• In children, blood cells are produced in the marrow
cavities of all the bones.
• Gradually, it gets replaced by fat (yellow marrow).
• In the adult blood cells are produced in the bone marrow
of selected bones (e.g. backbone – vertebral column,
ribs, bones of the skull, etc.)
16blood and blood transfusions
Bones require their own blood supply which travels through the
periosteum to the inner bone marrow.
18blood and blood transfusions
RED BLOOD CELLS
• RBCs are also called
• They are tiny (7.5u in diameter,
2u thick) biconcave discs.
• They survive for about 120
• RBCs are non nucleated
formed elements in the blood.
• The average normal RBC count
• for men 5.4 million/uL
• for women 4.5 million/uL
20blood and blood transfusions
Production of Erythrocytes: Erythropoiesis
• Hemoglobin is the most important
component of red blood cells.
• It is composed of a protein called
heme, which binds oxygen.
• In the lungs, oxygen is
exchanged for carbon dioxide.
• Abnormalities of an individuals
hemoglobin value can indicate
defects in red blood cell balance.
• Both low and high values can
indicate disease states.
21blood and blood transfusions
Formation of RBCs
• Takes place in the bone marrow.
• A feedback exists – if the RBC count
rises, further increases are inhibited.
• Low levels of oxygen in the
atmosphere stimulate the formation
• This is an important part of the
body’s adjustment to high altitudes.
People living in the mountains
actually do have higher RBC counts
• RBC formation is regulated by a
substance secreted by the kidneys.
• Destruction of RBCs
• About 5 X 10 11 RBCs are
destroyed everyday, in the liver
• Functions of RBCs
• Carriage of oxygen.
• Hemoglobin (Hb) – the red pigment
– acts as the vehicle for the
transport of oxygen from the lungs,
via the heart to the rest of the
• Also carries CO2, though greater
amounts of CO2 are transported
dissolved in plasma.
• Average Hb level in normal men
16gdL and 14gdL in normal
blood and blood transfusions 24
• Iron is essential for the synthesis of Hb.
• Hence after excessive bleeding iron supplements (tonics)
plus a diet rich in iron are necessary for more Hb to be
• Carriage of CO2 (less significant) – as described above,
most of the CO2 is dissolved in plasma.
• Presence of specific substances on their surface, which
are responsible for ‘typing’ blood into different groups.
blood and blood transfusions 25
Variations in number of RBCs
• High altitude
• Muscular exercise
• Emotional conditions
• Increased environmental
• High barometric pressure
• During sleep
blood and blood transfusions
WHITE BLOOD CELLS
• WBCs or leukocytes consists of 5
categories of cells.
• Each category has a distinct shape and
• Some cells are smaller than RBCs (5u in
diameter) whereas others are definitely
bigger (15 u in diameter).
blood and blood transfusions 29
Formation and destruction of WBCs
• The WBCs are formed in the bone marrow.
• The different categories of cells have different stimuli
for production. For e.g. one category (called
neutrophils ) are produced in large number whenever
there is short or severe (acute) infection.
• There life span also differs. Some categories (e.g.
neutrophils) may survive upto 7 hours.
• In contrast other cells ( lymphocytes ) are called ‘
memory cells .’
blood and blood transfusions 31
• They are able to ‘ remember’ an invader
for several months, even years.
• If the invader enters the body again, these
memory cells are alerted, and the body’s
response to the second invasion is much
more extensive and rapid.
blood and blood transfusions 32
Functions of WBCs
• WBCs are concerned with defense .
• Some of them are concerned with fighting acute (short,
severe) infections, whereas others fight chronic infections.
• Some WBCs are capable of moving in the tissues, acting
like vigilant guards.
• If they encounter a bacterium, they may consume it or
make it inactive.
• The pus which may be seen oozing out of an infected
wound, is made up of dead WBCs .
• A particular category of WBCs – the eosinophils – are
increased in allergic reactions and also in cases of worm
infestation. blood and blood transfusions 34
• The platelets are tiny bodies, 2-4um in diameter.
• There are about 0.25 to 0.4 million/uL of circulating blood.
• They have a half life of about 7 days.
• The platelets are called thrombocytes , because they
release thrombin , which aids in blood clotting.
blood and blood transfusions 35
Formation Large multinucleated cells that
pushes against the wall of the capillary.
Cytoplasmic extensions stick through and
blood and blood transfusions 36
• Provide overview of transfusion therapy.
• Describe pre-transfusion responsibilities.
• Describe transfusion responsibilities.
• Describe post-transfusion responsibilities.
• Describe types of transfusions.
• Describe transfusion reactions.
• Describe autologous transfusions.
blood and blood transfusions 38
• It is a procedure in which a patient
receives a blood product through an
• It is the introduction of blood components
into the venous circulation.
• Process of transferring blood-based
products from one person into the
circulatory system of another.
blood and blood transfusions 39
HISTORY OF BLOOD
• Before The Nobel Prize
awarded, Karl Landsteiner
discovered the ABO
human blood groups in
1901, it was thought that
all blood was the same.
This misunderstanding led
to fatal blood transfusions
and many death.
blood and blood transfusions 40
• Prof. Karl Landsteiner discovered that blood
clumping was an immunological reaction
• Karl Landsteiner's work made it possible to
determine blood types
• For this discovery he was awarded the Nobel Prize
in Physiology or Medicine in 1930.
blood and blood transfusions 41
• 450ml of blood can save as many as
• Every two seconds, someone in India
• One out of every three of us will need
blood in our life time.
• Even with all of today’s modern
technology, there is no substitute for
Someone has to give blood
in order for someone to
receive blood.blood and blood transfusions 42
•A person has 5 - 6 liters of blood in their
•A person can donate blood every 90 days (3
Body recovers the Blood very quickly:
• Blood plasma volume– within 24 - 48
• Red Blood Cells – in about 3 weeks
• Platelets & White Blood Cells – within
blood and blood transfusions 43
•To replace losses of: Circulating volume
Oxygen carrying capacity .
•To restore: Metabolic homeostasis.
•To replenish: Normal RBC’s (eg. Refractory
anemias, Thalasemias, Sickle cell anemias
•In cancer patients like ALL; AML; with /
orafter Chemothrapy drugs
• For emergency surgery, heart surgery
blood and blood transfusions 44
Typical Situations in which blood
products are given
• Major injuries after an accident or disaster
• Surgery on an organ such as the liver and
• Severe Anemia
• Bleeding such as Haemophilia and
• Pre-mature, pre term babies
• Cancer patients
blood and blood transfusions 45
What are the different blood
•There are more than 20 genetically
determined blood group systems known today
• The AB0 and Rhesus (Rh) systems are the
most important ones used for blood
• Not all blood groups are compatible with each
other. Mixing incompatible blood groups leads
to blood clumping or agglutination, which is
dangerous for individuals.
blood and blood transfusions 46
ABO blood grouping system
• According to
kinds of blood
types: A, B,
AB or O
blood and blood transfusions 47
AB0 blood grouping system
• Blood group A If you belong to
the blood group A, you have A
antigens on the surface of your
RBCs and B antibodies in your
• Blood group B If you belong to
the blood group B, you have B
antigens on the surface of your
RBCs and A antibodies in your
blood and blood transfusions 48
Blood group O
If you belong to the blood group
O (null), you have neither A or B
antigens on the surface of your
RBCs but you have both A and B
antibodies in your blood plasma.
blood and blood transfusions 49
Possible Blood group Genotypes
blood and blood transfusions 50
A B O
A AA AB AO
B AB BB BO
O AO BO OO
The ABO blood groups
• The most important thing is in assuring a safe blood
• The table shows the four ABO phenotypes ("blood groups")
present in the human population and the genotypes that give
rise to them.
blood and blood transfusions 51
Antibodies in Serum Genotypes
A A Anti-B AA or AO
B B Anti-A BB or BO
AB A and B Neither AB
O Neither Anti-A and anti-B OO
The Rhesus (Rh) System
• Well, it gets more complicated here, because
there's another antigen to be considered always -
the Rh antigen.
• Some of us have it, some of us don't have.
• If it is present, then blood is RhD positive, if not it's
• So, for example, some people in group A will have
it, and will therefore be classed as A+ (or A
• While the ones that don't, are A- (or A negative).
• And so it goes for groups B, AB and O.
blood and blood transfusions 52
What is that Rh antigens?
•Rh antigens are transmembrane proteins with
many loops exposed at the surface of red blood cells.
• They appear to be used for the transport of carbon
dioxide and/or ammonia across the plasma
• They are named for the rhesus monkey in which
they were first discovered.
• RBCs that are "Rh positive― Must express the
antigen designated as D.
• A person with Rh- blood does not have Rh
antibodies naturally in the blood plasma
blood and blood transfusions 53
• According to above blood grouping systems, you
can belong to either of following 8 blood groups:
blood and blood transfusions 54
• A person with Rh- blood can develop Rh antibodies
in the blood plasma if he or she receives blood from
a person with Rh+ blood, whose Rh antigens can
trigger the production of Rh antibodies.
• A person with Rh+ blood can receive blood from a
person with Rh- blood without any problems.
blood and blood transfusions 55
Laboratory Determination of the
blood and blood transfusions 56
blood and blood transfusions 61
Antigens Antibodies Can give
AB A and B None AB AB, A, B, O
A A B A and AB A and O
B B A B and AB B and O
O None A and B AB, A, B, O O
• Rh+ can receive blood from: Rh+ and Rh-
• Rh- can receive blood from: Rh- only
blood and blood transfusions 62
• Blood banks collect, test, and store blood.
• Autologous transfusion - If surgery is
scheduled months in advance, patients
may be able to donate their own blood and
have it stored.
blood and blood transfusions 63
• Blood products must be stored at 4C +-
• Stored blood has a shelf life of 3 weeks.
• After a storage time of 24-72 hr RBCs
have reduced capability to release oxygen
• If the patient needs massive transfusions
its better to give blood that’s less than 7
blood and blood transfusions 64
• Check the patient’s case note
• Transfusion history
• Special requirements
• e.g., irradiated, CMV
• Complete request form or
blood and blood transfusions 65
blood and blood transfusions 66
Patient Category NHS
Date of Request
Date of Specimen
Service (Type of Request)
Units (amount) Date Reqd
Vacutainer 7mls pink + 4.5 mls EDTA
Specimen taken by Sign and print Name Requesting Medic Sign and Print name
Copy of this request must be filed in the notes. See Trust Transfusion policy
Diagnosis, referral reason, relevant medication
Information found on the Request
• Assess laboratory values
• Verify the medical prescription.
• Assess the client’s vital signs, urine
output, skin color and history of
• Obtain venous access. Use a
central catheter or at least a 20-
gauge needle, if possible.
blood and blood transfusions 67
• Step 1: Ask the patient to tell you their:
Full Name + Date of Birth
• Check this information against
the patient’s ID wristband
• Be extra vigilant when checking
the identity of the unconscious /
blood and blood transfusions 68
Step 2: Check the patient’s ID wristband
e.g., case notes or request form for:
• First name
• Date of birth
• Hospital number
blood and blood transfusions 69
Only bleed one patient at a time using Aseptic
non touch technique
Do NOT use pre-labeled tubes
Label the sample tube beside the patient
Send the sample to the laboratory in the most
appropriate way for the clinical situation, i.e.
routine / emergency
Remember emergency requests must
always be phoned through to the
blood and blood transfusions 70
Labelling the venous blood sample
• Information to include:-
• Full name
• Date of birth
• Hospital number
• Signature of person who has taken
• At the bedside
• By the person taking the sample
blood and blood transfusions 71
IV Blood/ Blood Component
blood and blood transfusions 73
Prescribing a transfusion
• Each unit must be entered separately on
the patient’s prescription sheet.
• The entry must specify the type of product
any special requirements the rate of
transfusion – max 4hrs/unit
blood and blood transfusions 74
blood and blood transfusions 75
• Obtain blood products from a blood bank;
• With another registered nurse, verify the
patient by name and number, check blood
compatibility and note expiration time.
• Administer the blood product using the
appropriate filtered tubing.
blood and blood transfusions 76
Minimum Transfusion Dataset: the following should be
documented in the notes
• Reason for transfusion
• Current blood results
• Component type and amount to be prescribed
• Anticipated outcome
• Any reported transfusion adverse events/reactions
• Review following the transfusion including how
much blood has been transfused
blood and blood transfusions 77
• STORED BLOOD IS COLD 4*C
• PATIENTS UNDERGOING SURGERY WILL
ALREADY BE LOSING BODY HEAT DUE TO
WOUND OR CAVITY EXPOSURE
• LARGE VOLUMES OF COLD BLOOD MAY
INDUCE HYPOTHERMIA OR CARDIAC
blood and blood transfusions 78
• AT INFUSION RATES>100ml/minute, COLD BLOOD MAY BE A
CONTRIBUTING FACTOR IN CARDIAC ARREST. HOWEVER,
KEEPING THE PATIENT WARM IS PROBABLY MORE IMPORTANT
THAN WARMING THE INFUSEDBLOOD !
• WARMED BLOOD IS MOST COMMONLY REQUIRED IN
LARGEVOLUME RAPID TRANSFUSIONS & EXCHANGE
TRANSFUSION IN INFANTS.
• BLOOD SHOULD ONLY BE WARMED IN A BLOOD WARMER THAT
HAVE A VISIBLE THERMOMETER AND AN AUDIBLE WARNING
ALARM AND SHOULD BE PROPERLY MAINTAINED.
blood and blood transfusions 79
Can the Patient be Safely
• Is the product clearly prescribed?
• Are any drugs required before or during
transfusion? i.e. antibiotics
• Is the rate of transfusion appropriate?
• Does the patients condition require medical review prior to
All patients having a blood transfusion MUST have a NAMEBAND
containing all of their required details
blood and blood transfusions 80
Monitoring of Patient
Base line observations – Temperature, pulse and blood
Further observations (as above) at 15 minutes
A set of observations at the end of transfusion
More frequently if the patient is unwell, unobservable,
unconscious or a child.
blood and blood transfusions 81
• Ensure the venflon is secure, patent and there are no
signs of inflammation
• Give the patient the call bell
• Patients should remain in a clinical area for the
duration of the Transfusion
• Review the patients fluid balance and medication.
blood and blood transfusions 82
• Step 1: Check the blood component has
• Step 2: Undertake baseline observations
• Step 3: Undertake visual inspection
blood and blood transfusions 83
• Personal checks:
- wear personal protective equipment
• Equipment checks:
- Personal protective equipment is available and is clean
- A correctly completed prescription chart
- Observation chart
- Giving set
- Disposable bags
blood and blood transfusions 84
• Step 1: Ask the patient to tell you their
Full Name + Date of Birth
• Check this information against the
patient’s ID wristband
blood and blood transfusions 85
• Step 2: Check the patient’s
– First name
– Date of birth
– Hospital number
• on the compatibility/
traceability label against
the patient’s ID wristband
blood and blood transfusions 86
• Step 3: Check the
with the blood bag label
blood and blood transfusions 87
Blood Component Bedside
blood and blood transfusions 88
(Patient and Unit)
• Remain with the patient during
the first 15-30 minutes of the
• Infuse the blood product at the
• Monitor vital signs.
blood and blood transfusions 89
• Stop the Transfusion and seek Medical Input and inform the
Transfusion Laboratory staff
• Check the Blood component matches the patient details
• Replace the unit and giving set with Normal Saline 0.9%
• Send the discontinued unit with giving set attached back to
transfusion capped off at the end with a white venflon cap – and any
previous transfused bags sealed with the blue plugs all in biohazard
• Documentation (complete the checklist)
• Complete a Trust Incident form
blood and blood transfusions 90
TYPES OF TRANSFUSION
blood and blood transfusions 92
Types of BT
• Based on time of transfusion
• Fresh whole blood transfusion
• Stored CPD Blood
• Based on composition
• Whole blood
• Blood fraction
• Based on the donor
• Autologous blood transfusion
• Blood from diff donor
blood and blood transfusions 93
Packed Red Blood Cells Platelet Rich Plasma
High Speed Centrifugation
1 Unit of Random Donor
1 Unit of Fresh Frozen Plasma
Thawing precipitates the
• 4 for up to 35 days
• Massive Blood Loss/Trauma/Exchange
• Use filter as platelets and coagulation
factors will not be active after 3-5 days
• Donor and recipient must be ABO
• 4 for up to 42 days, can be frozen
• Many indications—ie anemia, hypoxia,
• Recipient must not have antibodies to
donor RBC’s (note: patients can
develop antibodies over time)
• Usual dose 10 cc/kg (will increase Hgb
by 2.5 gm/dl)
• Usually transfuse over 2-4 hours
(slower for chronic anemia
• Up to 5 days at 20-24
• Thrombocytopenia, Plt <15,000
• Bleeding and Plt <50,000
• Invasive procedure and Plt <50,000
• Contain Leukocytes and cytokines
• 1 unit/10 kg of body weight increases Plt count
• Donor and Recipient must be ABO identical
Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml)
• Comes in 200ml bags.
• FFP--12 months at –18 degrees or colder
• Coagulation Factor deficiency, fibrinogen
replacement, DIC, liver disease, exchange
transfusion, massive transfusion
• Plasma should be recipient RBC ABO
• In children, should also be Rh compatible
• Account for time to thaw
• Usual dose is 20 cc/kg to raise coagulation
factors approx 20%
• Precipitate formed/collected when FFP is
thawed at 4
• After collection, refrozen and stored up to 1
year at -18
• Fibrinogen deficiency or dysfibrinogenemia
• vonWillebrands Disease
• Factor VIII or XIII deficiency
• DIC (not used alone)
• ABO compatible preferred (but not limiting)
• Usual dose is 1 unit/5-10 kg of recipient body
• Prepared at the time for immediate
transfusion (no storage available)
• Indications – severe neutropenia
assoc with infection that has failed
antibiotic therapy, and recovery of
BM is expected
• Donor is given G-CSF and steroids
• Severe allergic reactions
• Can irradiate granulocytes for GVHD
• Used for prevention of transfusion
• Filter used with RBC’s, Platelets,
• Other plasma proteins (albumin,
colloid expanders, factors, etc.) do
not need filters—NEVER use filters
with stem cell/bone marrow
• May reduce RBC’s by 5-10%
• Does not prevent Graft Verses Host
• Typing of RBC’s for ABO and Rh are
determined for both donor and recipient
• Screen RBC’s for atypical antibodies
• Approx 1-2% of patients have
• Donor cells and recipient serum are
mixed and evaluated for agglutination
• Supplied in 250ml bags.
• Usual dose of 10 cc/kg infused over 2-4 hours
• Maximum dose 15-20 cc/kg can be given to
hemodynamically stable patient
• May need Premedication (Tylenol and/or
• Filter use—routinely leukodepleted
• Monitoring—VS q 15 minutes, clinical status
• Do NOT mix with medications
• Rapid infusion may result in Pulmonary edema
• Transfusion Reaction
• ABO antigens are present on
• ABO compatible platelets are ideal
• This is not limiting if Platelets indicated
and type specific not available
• Rh antigens are not present on
• Note: a few RBC’s in Platelet unit may
sensitize the Rh- patient
• May be given as single units or as apheresis units
• Usual dose is approx 4 units/m2—in children using 1-2
apheresis units is ideal
• 1 apheresis unit contains 6-8 Plt units (packs) from a
• Should be administered over 20-40 minutes
• Filter use
• Premedicate if hx of Transfusion Reaction
• Complications—Transfusion Reaction
• Collection/infusion of client’s own blood
• Preoperative autologous blood donation
• Acute normovolemic hemodilution
• Intra-operative autologous transfusion
• Postoperative blood salvage
blood and blood transfusions 106
Preoperative autologous blood
• Collecting whole blood from the client,
dividing it into components and storing it
for later use
• Can be collected weekly as long as client’s
H&H are within safe range
• Can be stored up to 40 days; up to 10
years for rare blood types.
blood and blood transfusions 107
• Withdrawal of client’s RBCs and volume
replacement just before a procedure
• Goal is to decrease RBC loss during
• Blood is stored at room temperature for up
to 6hrs and reinfused after surgery.
• Not for anemic clients or those with poor
blood and blood transfusions 108
transfusion & Post operative
• Recovery/reinfusion of client’s own blood
from operative field or bleeding wound.
• Special devices collect, filter, drain blood
into transfusion bag
• Used for trauma or surgical patients with
severe blood loss
• Blood must be reinfused within 6 hours.
blood and blood transfusions 109
blood and blood transfusions 110
Observing / Monitoring the Patient During a Blood / Blood
Component Transfusion is part of safe transfusion
Tachycardia Hyper /
muscle, bone or loin
• DIC is the abnormal activation of the coagulation and
fibrinolytic systems,resulting in the consumption of
coagulation factors and platelets.
• DIC may develop during the course of massive blood
transfusion,although its cause is less likely to be due to the
transfusion itself than related to the underlying reasons for
• Hypovolaemic shock
• Obstetric complications
blood and blood transfusions 118
• Treatment of DIC should be directed at
correcting the underlying cause and at
correction of the coagulation problems as
blood and blood transfusions 119
Transfusions of blood & blood components
are labour intensive & expensive but are
frequently life saving
In a few patients, however they can result in
potentially fatal complications.
It is therefore essential that they are only
given when the benefits outweigh the risks