Blood Transfusion Guideline: 6 Edition

6th Edition
Blood Transfusion Guideline

Table of Contents
Foreword .......................................................................................................................................... 3
Preface........................................................................................................................................................... 4
1. Introduction...................................................................................................................................... 5
2. General Indications for the Use of Blood and Blood Components .................................. 6
2.1. Red Cell Transfusion in Acute Blood Loss ................................................................... 6
2.2. Other Circumstances when Red Cell transfusion may be needed ............................. 7
Guideline for Red Cell Transfusion in patient with Persistent Chronic Anaemia .. 8
Guideline for Red Cell Transfusion in patient going for Operation ....................... 8
Pre-Operative Blood Transfusion ................................................................ 8
Peri-Operative Blood Transfusion ............................................................... 9
Post-Operative Blood Transfusion .............................................................. 9
Additional requirements for Red Blood Cells ............................................. 9
2.3. Platelets Transfusion ................................................................................................10
2.4. Fresh Frozen Plasma Transfusion .............................................................................11
2.5. Cryoprecipitate Transfusion .....................................................................................12
2.6. Factor VIII & Factor IX Concentrates Transfusion ....................................................13
2.7. Intravenous Immunoglobulin Transfusion................................................................13
2.8. Plasma Substitutes Transfusion................................................................................13
2.9. Further Guidelines for Ordering Blood and Blood Products ....................................13
2.10. Massive Transfusion Protocol ..................................................................................14
3. Guidelines on Administration of Blood and Blood products..........................................................16
3.1. Indications ................................................................................................................16
3.2. Group and Cross-match ............................................................................................16
3.3. Emergency Blood Transfusion ..................................................................................16
3.4. Pre-transfusion Blood Sampling ...............................................................................17
3.5. Administration of Blood and Blood Products ...........................................................18
4. ABO Group of Blood Components Compatible for Transfusion (NOT APPLICABLE for ABO-
incompatible transplant patients) ..................................................................................................20
5. Replacement Clotting Factor Treatment for haemophilia .............................................................21
5.1. Factor Concentrate level guidelines .........................................................................21
5.2. Haemophilia A ..........................................................................................................21
5.3. Haemophilia B ..........................................................................................................22
6. Storage of Blood and Blood Components ......................................................................................23
6.1. Storage of Whole Blood and Red Cell Concentrates ................................................23
6.2. Storage of Fresh Frozen Plasma and Cryoprecipitate ..............................................23
6.3 Storage of Platelets ...................................................................................................23
7. Transportation of Blood and Blood Products .................................................................................24
8. Transfusion Hazards and Reactions ...............................................................................................25
9. Autologous Blood Donation for Elective Surgery ...........................................................................26
9.1. Pre-surgical donation and storage ...........................................................................26
9.2. Acute Nomovolaemic haemodilution and short term storage ................................26
9.3. Intra-operative blood salvage and re-transfusion ....................................................28
10. Using SGH Autologous Blood Clinic (ABC) ......................................................................................29
10.1. Advantages of pre-surgical Autologous Blood Donation .......................................29
10.2. Criteria for Acceptance on Pre-surgical Autologous Blood Donation ...................29
10.3. How to Schedule ....................................................................................................29
11. Using the SGH Blood Bank Laboratory ..........................................................................................31
12. Guidelines for the Procurement of Blood for Elective Surgery .....................................................32
FOREWORD
"SGH Blood Transfusion Guidelines for Medical, Nursing and Laboratory Staff" is published as a
reference for all staff who are involved in the blood transfusion of patients.
These guidelines have been compiled to facilitate cross-reference reading by doctors, nurses and
laboratory staff as the procedures in carrying out blood transfusion; are often inter-linked. It will help
prevent confusion in responsibilities by the various parties involved in blood transfusion.
The SGH Blood Transfusion Committee audits blood transfusion practices and continues to organize
continuing education programmes on Transfusion Medicine for staff of SGH. The Annual Blood
Transfusion Seminars target junior doctors, nurses and laboratory staff who join the hospital and are not
familiar with SGH practices. Quality assurance to ensure that blood transfusion is safe and effective is
part of the audit. It will also reduce wastage of blood and blood products, as these are very precious
resources that cannot be easily replaced or substituted.
Getting donors has been an uphill task for the Blood Services Group (BSG). Therefore, it is incumbent on
us to ensure that every unit of blood collected is not wasted as a result of carelessness. Adverse blood
reactions can also be fatal to patients. Therefore, it is imperative for all staff to read these guidelines
and follow the instructions to prevent mistakes or wastage of blood.
I wish to take this opportunity to commend A/Prof. Tien Sim Leng, Chairman, SGH Blood Transfusion
Committee, and his Committee Members for their hard work and effort in producing this booklet of
guidelines for all our staff. It is a valuable resource and reference in all departments of the hospital.
CHAIRMAN MEDICAL BOARD
SINGAPORE GENERAL HOSPITAL
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SGH Blood Transfusion Guideline (6th Edition) Page 3

PREFACE
The practice of transfusion medicine has evolved so rapidly that blood transfusion is not just giving
"whole blood" but giving specific blood components with specific indications. Separation of blood into
component parts allows at least three patients with different deficiencies to benefit from each donor's
contribution. Specific blood components like red cells and platelets can also be made "purer" by
leucodepletion techniques to reduce white-cell contamination for use in certain clinical situations. Purer
clotting-factor concentrates are also possible with improvement in various fractionation techniques. The
changes in the technology of blood transfusion and its practice are so numerous that a condensed on-
line Guideline like this becomes necessary and relevant.
The SGH Blood Transfusion Committee, with assistance from the Department of Quality Management,
has compiled this Guideline to guide doctors, nurses and laboratory staff on various aspects of the blood
transfusion process, ranging from the laboratory to the patient's bedside. The guidelines for blood
transfusion from the SGH Blood Bank Laboratory and HSA-MOH Clinical Practice Guidelines 1/2011 1
have been adapted and included. The ultimate aim is to have a safe and effective blood component
therapy for patients in SGH.
In this on-line fifth edition for the year 2013, we have updated some of the information in tandem with
current practices and processes. While we attempt to be as comprehensive and up-to-date as possible,
we realize that this Guideline has to be revised regularly with the continuing changes in transfusion
practice. We welcome feedback from all staff in SGH.
A/PROF TIEN SIM LENG CHAIRMAN
SGH BLOOD TRANSFUSION COMMITTEE
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1
Ministry of Health (Singapore), Health Sciences Authority and Academy of Medicine (Singapore).
Clinical Blood Transfusion, HSA-MOH Clinical Practice Guidelines 1/2011.
Ministry of Health, Singapore Inc; 2011. Available from:
http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medica
l/2011/cpgmedclinical_blood_transfusion.html
1. INTRODUCTION
This guideline only serves as a guide for SGH doctors, nurses and laboratory staff on various aspects of
the transfusion process so as to promote appropriateness and safety of transfusion practices within
SGH. It is NOT meant to set the standard of care which may be constantly evolving with the emergence
of new scientific knowledge and developments. The staff should bear in mind that each patient or
clinical scenario may be different, and they will have to exercise discretion and professional judgement
appropriate for individual patients when applying this guideline. The reader is also encouraged to refer
to the HSA-MOH Clinical Practice Guidelines 1/2011 2 which provides broader coverage of the guidelines
on clinical blood transfusion.
The SGH Blood Bank Laboratory obtains its blood stock from the Blood Services Group (BSG), Health
Sciences Authority (HSA). No charge is made for the blood used by any patient. Patients have to pay
only a blood processing fee. This fee is chargeable according to a set scale determined by the Ministry of
Health.
These facts must be stressed to patients who are to receive blood so that they do not go away with any
misconception that they have been made to pay for the blood.
Before giving blood or blood product transfusion, written informed consent is to be taken and the
recipient should be informed of its complications and the need for transfusion based on clinical
indications. For elective surgery, the patient should be given the option to have autologous blood
transfusion if deemed suitable and whenever possible. For patients anticipated to need blood
transfusions, a Patient Information Leaflet on Blood Transfusion (produced by HSA) will be made
available in the wards or clinics where patients are expected to need blood transfusion. This may serve
as an aide for patients to understand the blood transfusion process and its potential risks. However, it is
still the doctor’s primary responsibility to explain to the patients and ensure that they understand about
blood transfusion and its risks before giving consent.
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2
Ministry of Health (Singapore), Health Sciences Authority and Academy of Medicine (Singapore).
Clinical Blood Transfusion, HSA-MOH Clinical Practice Guidelines 1/2011.
Ministry of Health, Singapore Inc; 2011. Available from:
http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical/2011/cp
gmedclinical_blood_transfusion.html
2. GENERAL INDICATIONS FOR THE USE OF BLOOD AND BLOOD COMPONENTS
It should be emphasized that blood and blood products should be administered only when they are
clearly indicated and that safer alternatives should be used whenever possible. It must be remembered
that transfusion of blood and blood components is not without potential risks and complications.
Replacement therapy should consist only of the component(s), which the patient needs, administered in
the smallest volume possible.
2.1 Red Cell Transfusion in Acute Blood Loss

In patients with acute blood loss, restoration of blood volume is more important than red cell
replacements. Fluids can be used initially in these circumstances, reducing the need for blood
transfusion.
Following acute blood loss, haemoglobin and haematocrit may remain normal or nearly normal for an
hour or more, until there is equilibrium between the intravascular space and the extravascular fluid.
Patients with acute haemorrhage may require transfusion despite normal haemoglobin and
haematocrit levels. In most patients, loss of approximately 20% of blood volume can safely be corrected
by crystalloid solutions alone.
Red cells will be required when anoxia develops or is likely, and red cell transfusion is
appropriate in these circumstances. The risk of this happening increases considerably when the blood
loss exceeds 25% of the total blood volume. Thus, the need to replace blood depends on the estimation
of the volume of loss and the rate of loss. Red Cell transfusion has the capability of increasing oxygen
carrying capacity which cannot be achieved with fluid replacement alone. The red cell transfusion may
be supplied as red cell concentrates or whole blood, usually depending on the availability in the
inventory.
A sudden loss of 30% of the total blood volume (i.e. haemorrhage of 1.5 L in a 70-kg person) requires
urgent correction. Fifty percent (i.e. 2.5 L in a 70-kg person) loss of blood volume is fatal in the absence
of immediate treatment. On the other hand, a <30% loss in red blood cells alone in a previously fit
person may not be clinically significant and can be treated by Blood Volume Expanders alone. This order
of loss stimulates bone marrow activity and leads to rapid restoration of the red cell mass.
Guidelines for Red Cell Transfusion during Acute Blood Loss

1. Assess the extent of blood loss/patient's intravascular volume status.
2. Adequately restore the intravascular volume of all patients with crystalloid.
3. Clinical decision for blood transfusion depends on the estimation of blood loss, rate of on-going
blood loss, Hb prior to bleeding, evidence of end organ dysfunction or compromise of
cardiopulmonary reserve (table A) and patient’s risk factors (table B). Measurement of Hb level
may be misleading during acute blood loss and should not be used as the sole indictor of the
amount of blood loss. Achievement of haemostasis is the most important measure in the
management of acute blood loss
4. Administer transfusion(s) on a unit-by-unit basis.
5. Evaluate the patient after each unit.
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Table A - Signs and symptoms suggestive of Table B - Patient groups at risk of compromised
compromised cardiopulmonary reserve cardiopulmonary reserve from acute blood loss
 Syncope  Patients at risk of Myocardial Ischaemia
 Dyspnoea  Coronary Artery Disease
 Postural Hypotension  Valvular Heart Disease
 Tachycardia  Congestive Cardiac Failure
 Angina  Patients at risk of Cerebral Ischaemia
 Transient Ischaemic Attack  History of Transient Ischaemic Attacks
 Previous Thrombotic Strokes
 Patients with respiratory diseases
2.2 Other Circumstances when Red Cell transfusion may be needed

Red cell transfusion may also be needed in the following circumstances:
1. Slow continuous blood loss.
2. Pre- and post-operation transfusion requirements.
3. Severe and/or symptomatic chronic anaemia due to causes such as bone marrow failure,
uraemia and severe haemonitic deficiency (In haemonitic deficiency, blood transfusion may
often be avoided with appropriate replacement of the haemonitics unless anaemia is
severe and/or patient is significantly symptomatic which require more rapid improvement
of Hb with blood transfusion)
4. Acute and chronic leukaemia
The patient's condition, not a laboratory test result, is the most important factor in determining
transfusion needs. Many types of asymptomatic anaemia do not require transfusion. When anaemia
develops slowly, compensatory mechanisms occur, such as increased cardiac output and a right shift of
the oxyhaemoglobin dissociation curve, which enhances oxygen delivery to the tissues. These
mechanisms lessen somewhat the physiological impact of reduced haemoglobin levels. For patients with
chronic anaemia, it is important to diagnose and treat the cause of anaemia, not merely restore
haemoglobin by transfusion. Since transfusion is not without risks and is only a temporarising measure,
it should be used only when the benefits outweigh the risks and if there are no other safer alternatives
to achieve similar clinical benefits. Most patients adapt well to chronic anaemia and need transfusion
only when their hypoxia becomes severe enough to cause symptoms. Thus for eg, patients with chronic
haemolytic anaemia would generally not require transfusion in the steady state, but only when the
haemoglobin falls abruptly in aplastic crisis or splenic sequestration crisis. In general, red cell
transfusions should not be considered when treatment of the underlying cause will significantly reduce
the severity of or correct the anaemia. For example, transfusions are usually not indicated in patients
with nutritional anaemias because they will respond to the appropriate haematinic.
In preoperative and postoperative patients, red cell transfusion should not be given just to achieve a
target Hb and should be based on proper clinical evaluation. For elective operations, preoperative
evaluation should be done well in advance to allow sufficient time for the identification of patients at
risk of requiring transfusion and the reduction of such risk, including the evaluation and correction of
the underlying cause for anaemia and coagulopathy prior to the operation.
The blood volume of patients with chronic anaemia is normal or increased. Whole blood is usually not
suitable in such patients because the plasma, which is not required, increases the volume of fluid
transfused and, therefore, the risk of circulatory overload.
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One unit of red cells should raise the non-bleeding adult patient's haemoglobin by about 1 g/dL and the
haematocrit by about 3%. Transfused cells have shortened survival in patients with acute bleeding and
in those patients with haemolysis due to alloantibodies, autoantibodies or hypersplenism.
Guidelines for Red Cell Transfusion in Patients with Persistent Chronic Anaemia
1. Administer transfusion(s) on a unit-by-unit basis. Evaluate the patient after each unit. One unit
may be sufficient.
2. Restore intravascular volume with crystalloids.
3. There is usually very little indication for red cell transfusion when Hb is >10g/dL. When Hb is
<7g/dL, red cell transfusion may be beneficial particularly in symptomatic patients (table A) or
when ongoing blood loss is anticipated. In normovolaemic anaemia with Hb 7-10 g/dL, red cell
transfusion should be guided by symptoms (table A) and patients’ comorbidities (table B) and in
such situations, red cell transfusion may not be indicated unless deterioration in vital signs occurs
or the patient develops symptoms .
4. Correct underlying causes of the anaemia e.g. iron deficiency by giving the appropriate treatment
rather than depending on transfusion alone. Red cell transfusion should not be given for
inappropriate reasons as listed in table C.
Table C - Blood transfusion should not be given for the following reasons
 Enhancement of general sense of well-being.

 In place of a haematinic.
 To expand vascular volume when it is adequate or crystalloids will suffice.
 Prophylactically, in the absence of risk factors.
 To promote wound healing.
Guidelines for Red Cell Transfusion in patients going for operations

Red cell transfusion should not be given to surgical patients just to achieve a target Hb but should be
based on proper clinical evaluation and careful consideration of other alternatives.
Pre-Operative Blood Transfusion

1. Proper preoperative evaluation of elective surgical patients should be done well in advance
(usually at least 1 month earlier) to identify, correct and derive management plans for risk factors
associated with transfusion.
2. There is usually very little indication for blood transfusion when Hb is > 10g/dL.
3. Transfusion is usually not indicated in patients with a haemoglobin of at least 8 g/dL when:
a. The patient is well compensated with chronic anaemia and anticipated blood loss is minimal.
b. A healthy patient is undergoing an intra-operative normovolaemic haemodilution
4. When the anaemia cannot be corrected by other measures or if there is insufficient time to
correct the underlying aetiology of anaemia in more urgent operations, transfusion may be
indicated in patients with a Hb of > 8 to <10 g/dL when:
a. There is expected to be significant blood loss.
b. The patient is unable to increase cardiac output in response to bleeding.
c. The patient has conditions which increase oxygen demand (infection, bronchospasm, chronic
obstructive lung disease).
d. The patient has decreased cardiac reserve (eg. atrial fibrillation, ischaemic heart disease).
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Peri-operative Blood Transfusion
Available evidence does not support the use of a single criterion for transfusion, such as haemoglobin
concentration of less than 10 g/dL. It should be based on clinical assessment of patient’s condition.
Minimum pre-operative haemoglobin of 8 g/dL is usually considered acceptable for patients with
sufficient cardiorespiratory reserves undergoing surgeries with minimal anticipated blood loss. This
same value is considered acceptable intra-operatively for patients with no significant systemic diseases
and minimal anticipated blood loss, as well as postoperatively for patients without acute myocardial or
cerebrovascular ischaemia. A higher haemoglobin level may be required for:
1. Patients unlikely to be able to increase cardiac output or regional blood flow to compensate
adequately for decreased oxygen carrying capacity.
2. Frail, elderly patients.
3. Post-operative patients requiring mechanical ventilation and/or those with complications
increasing the VO2 or decreasing cardiac reserve.
Post-Operative Blood Transfusion

1. In the absence of acute myocardial infarction or cerebrovascular ischaemia, transfusion is
generally not indicated if the Hb is at least 8g/dL. There is no convincing evidence that a liberal
transfusion strategy (transfuse if Hb <10g/dL) improves postoperative mobility, mortality and
rates of acute coronary events over a restrictive strategy (transfuse only if symptomatic or at
physician discretion if Hb <8g/dL) in high cardiovascular risks patients after hip surgery 3.
2. Transfusions may be needed in patients with a Hb > 8 to <10 g/dL when:
a. The patient has acute myocardial infarction or cerebrovascular ischaemia
b. The patient falls into any of the categories from 4b to 4d under “Pre-operative Blood
Transfusion” and has continued significant blood loss into the surgical drains (Surgical
intervention for haemostasis may be required if postoperative blood loss is significant).
3. It is recommended that the haemoglobin/haematocrit levels should be checked regularly if there
is ongoing blood loss and in older patients with cardiopulmonary disease.
Additional Requirements of Red Blood Cells

The target residual leucocyte number in a leucocyte-depleted Red Cell unit should be less than 5 x 106.
The recommended indications for leucocyte-depleted red blood cells are as follows:
1. To abolish or ameliorate recurrent (two or more consecutive) non-haemolytic febrile transfusion
reactions to red cell transfusion.
2. To reduce HLA alloimmunisation especially in patients who are red-cell- transfusion dependent.
3. As a means to reduce transfusion transmitted CMV infections in susceptible CMV-seronegative
patients (such as pregnant patients, HIV patients and low birth weight premature neonates),
intrauterine transfusions (need to be irradiated too), and other immunocompromised patients
(eg.stem cell transplant patients).
For leucocyte-depleted red-cell transfusion, bedside leucocyte filter can be obtained from the SGH
Blood Bank Laboratory or prestorage leucodeplted blood can be requested from BSG.
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3
(Carson J L et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365:
2453-62)
Washed red cells are usually indicated in:
1. Patients with a history of anaphylactic reaction to blood components.
2. IgA deficiency with documented anti-IgA antibodies.
3. Recurrent severe urticarial reactions not prevented by pre-transfusion administration of
antihistamines.
The Blood Services Group (BSG) should be given advanced notice when transfusions are required in
such patients so as to ensure adequate time to prepare the component. Washed red cells also have a
short shelf-life of only 24 hours after being processed.
Irradiation of red cells and other cellular blood components (platelets, granulocytes) prevents
transfusion-associated graft versus host disease (often a fatal complication) and is indicated in:
1. Intrauterine transfusions
2. Blood components from 1st or 2nd degree relatives (rarely would blood components come from
close relatives as replacement blood donation is no longer practised in Singapore, except in
situations of rare blood groups or rare red cell alloantibodies when compatible red cells from
voluntary blood donors are not available)
3. HLA-compatible cellular blood components
4. Patient who have received purine nucleoside analogues chemotherapy (eg. fludarabine,
pentostatin, cladribine, clofarabine), ATG and alemtuzumab
5. Stem cell donors (start seven days prior to stem cell harvesting until after completion of stem cell
harvesting)
6. Patients who have undergone autologous stem cell transplant (up to six months after autologous
stem cell transplant; for indefinite period if previous exposure to agents stated in 4. above)
7. Patients who have undergone allogeneic stem cell transplant
8. Top up and exchange transfusions in neonates who had history of intrauterine transfusions
9. Patients with congenital T-cell immunodeficiency defects
10. Granulocytes transfusions
Irradiated cellular components are also recommended in neonatal exchange transfusions (without prior
intrauterine transfusions) and patients with Hodgkin’s disease provided that irradiation does not cause a
clinically significant delay. In emergency situations, standard blood components should be transfused if
irradiated blood components are not available,
2.3 Platelets Transfusion

Platelets may be indicated for managing patients who have thrombocytopenia or qualitative platelet
disorders. In managing thrombocytopenic patients, it is important to treat the patient and not the
platelet count. The decision to transfuse platelets depends on the clinical condition of the patient, the
cause of the thrombocytopenia, the platelet count and the functional ability of the patient's own
platelets.
Spontaneous bleeding rarely occurs with platelet counts greater than 20 x 109/L in clinically stable
patients with no other risk factors for bleeding. Requests for platelets must be made in consultation
with the doctor at BSG when the platelet count is >20 x 109/L. If in doubt, consultation may also be
made with the haematologist.
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Therapeutic Platelet Transfusion
Therapeutic platelet transfusion may be appropriate for haemostasis in patients with significant
haemorrhage in the following situations:
1. When there is thrombocytopenia, generally when platelet count is <50X109/L (different threshold
may apply depending on the site of bleeding and severity of bleeding)
2. Acquired or congenital platelet dysfunction
Prophylactic platelet transfusion
Prophylactic platelet transfusion is appropriate in the following situations:
1. Patients with thrombocytopenia from impaired bone marrow function when platelet count is <
10X 109/L and there are no other risk factors for bleeding. These patients may need to be given
prophylactic platelet transfusion when platelet count is < 20X 109/L if there are other risk factors
for bleeding (eg. sepsis, acute promyelocytic leukaemia, coagulopathy)
2. Patients with thrombocytopenia of < 50X 109/L who are going for surgery or invasive procedures
(In the presence of other risk factors for bleeding eg. coagulopathy, a higher target platelet count
may be needed)
3. Patients with platelet dysfunction who are going for surgeries or invasive procedures
Platelet counts of at least 100 x 109/L may be necessary for adequate haemostasis in patients
undergoing critical site surgeries (eg. brain and eyes), or when there is massive haemorrhage from
severe multiple trauma. After a transfusion of about 2 times total blood volumes of whole blood or red
cells, platelet counts often fall below 50 x 109/L. The decision to administer platelets should rest on the
actual count, and not on a replacement formula based on the number of units transfused. In patients
with massive haemorrhage (eg. trauma patients), earlier transfusion of platelet count with red cells and
plasma while awaiting for the platelet count result may help to improve outcome (see Massive
Transfusion Protocol in J).
Platelet transfusions are of limited or transient value in patients in whom the thrombocytopenia is due
to increased destruction (e.g., immune thrombocytopenia), and are generally contraindicated in
conditions with increased platelet activation and aggregation (eg. thrombotic thrombocytopenia
purpura (TTP), heparin-induced thrombocytopenia (HIT)) unless the patients also have significant
concurrent bleeding.
BSG provides platelets as pooled from 4 donors or aphaeresis platelets from single donors (CSP), both of
which are leucodepleted. The indications for irradiated platelets are similar to that of red cells.
2.4 Fresh Frozen Plasma Transfusion

Fresh frozen plasma (FFP) contains all the clotting factors and natural anticoagulants but the
concentration of these factors may vary from unit to unit.
Clinical indications of FFP include:
1. Treatment of Thrombotic Thrombocytopenia Purpura (TTP) in conjunction with plasma exchange.
2. Cases in which FFP is used as a source of Anti-Thrombin III, Protein C and Protein S in patients
with inherited deficiencies when the individual factors are not available.
3. Deficiency in C1 esterase inhibitor during episodes of severe angio-oedema when specific therapy
is not available.
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4. Replacement of single-factor deficiencies (in situations when replacement is indicated) when
specific or combined concentrates are not available.
FFP is indicated in the following disorders only in the presence of bleeding or when invasive procedures
and surgeries are planned:
1. Massive transfusion - defined as the replacement of a patient's total blood volume within 24
hours.
2. Immediate reversal of warfarin effect in patients (Vitamin K should be given concurrently) if 4-
factor prothrombin complex concentrate is not available. FFP is not indicated in warfarinised
patients who do not need immediate reversal of warfarin (i.e. not bleeding, not going for urgent
surgery or invasive procedure). If such patients are significantly overwarfarinised, vitamin K
replacement is the treatment of choice.
3. Liver disease - only if bleeding has taken place or may be expected from proposed surgery. As a
result of the variety of coagulation abnormalities in patients with liver disease, complete
correction is often very difficult.
4. Haemorrhagic disease of the new-born and other vitamin K-associated coagulation deficient
states (IV Vitamin K should be given concurrently).
5. Disseminated Intravascular Coagulation (DIC).
6. In plasma exchange procedures for TTP and atypical haemolytic uraemic syndrome (HUS); and in
other indications, only if bleeding occurs in the presence of coagulation abnormalities. As
haemorrhagic episodes are rare, there is no place for routine replacement with FFP in other
indications besides TTP and atypical HUS.
FFP should not be blindly given to correct an incidental prolonged coagulation profile (PT or APTT) as
these have not been found to correlate well with bleeding risk. A comprehensive personal and family
history of bleeding is a good preoperative screening of bleeding for surgical patients. As much as
possible, the underlying cause for the abnormal coagulation profile should be investigated as not all
prolonged coagulation profile is associated with a bleeding tendency (eg. lupus anticoagulant) or can be
corrected by FFP transfusion (eg. clotting factor inhibitor).
The use of FFP is not justified in the treatment of hypovolaemia or as a source of immunoglobulin and
albumin. It is not useful in the reversal of heparin. Transfusing FFP for volume expansion carries the risk
of transfusion-transmitted diseases and other complications of transfusion that can be avoided by using
crystalloid or colloid solutions.
All requests for FFP must be made in consultation with the doctor at BSG when it does not meet the
predefined requirement (see I). If in doubt, consultation may be made with the haematologist.
2.5 Cryoprecipitate Transfusion

Cryoprecipitate (CRYO) is rich in Factor VIII, fibrinogen and von Willebrand factor (vWF). Currently, the
primary clinical use of CRYO is for the intravenous supplementation of fibrinogen, the fibrinogen content
of CRYO is usually used for the treatment of dysfibrinogenaemia or hypofibrinogenaemia, either
occurring as a rare isolated congenital deficiency or acquired conditions such as DIC, especially in the
bleeding patient.
In SGH, CRYO should not be used for factor replacement in patients with von Willebrand diseases or
Haemophilia A as appropriate virally inactivated concentrates are available in SGH blood bank
laboratory.
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2.6 Factor VIII & Factor IX Concentrates Transfusion
Viral-inactivated Factor VIII or Factor IX concentrates are available at the SGH Blood Bank Laboratory for
the treatment of Haemophilia A and Haemophilia B respectively. Recombinant FVIII is also available in
SGH Blood Bank Laboratory. For home treatment, factor concentrates are also available at the National
Haemophilia Registry and Haemophilia Treatment Clinic. Recombinant factor VIIa is also available at SGH
Blood Bank Laboratory for treatment. Please refer to section on Replacement clotting factor treatment
for Haemophilia for guidelines on treatment.
2.7 Intravenous Immunoglobulin Transfusion

Intravenous Immunoglobulin is used in certain clinical situations, e.g., idiopathic thrombocytopenia,
Guillain-Barre Syndrome or bone marrow transplants. This product is available at the SGH Blood Bank
Laboratory and the request should be made in the "Request Form for Blood and Blood
Products".
2.8 Plasma Substitutes Transfusion

Plasma substitutes, chiefly 5% and 20% albumin solutions and plasma protein fraction, provide volume
expansion and colloid replacement without risk of hepatitis. Albumin solutions do not correct nutritional
deficiencies. In cost per calorie, albumin is the most expensive nutrient supplied. Nutritional
hypoalbuminaemia is best treated by enteric or parenteral alimentation or hyperalimentation. Patients
with chronic liver disease, notably cirrhosis, have abnormalities of albumin distribution and production,
but transfusion of albumin does not alter these abnormalities.
These are most widely available at concentrations from 12.5g/250ml to 10g/50ml. The chief
indications for their use are in replacement of albumin after large volume abdominal paracentesis and in
patients undergoing plasma exchange for indications other than TTP or atypical HUS.
2.9 Further Guidelines for Ordering Blood and Blood Products

1. The following blood and blood products require a discussion to be conducted with the BSG
Medical Officer before calling the SGH Blood Bank Laboratory:
a. Red cell and platelet requests for D-negative patients
b. Washed Red Cells
c. Irradiated red cell and platelets
d. Red cell requests when Hb is >7g/dL and patient is not symptomatic/bleeding, or when
request for >2units
e. Platelets when platelet count is > 20 X 109/L, requesting for > 1 unit of pooled platelets or
CSP, <6 hours from last platelet issue, requests for aphaeresis paediatric platelets (APP)
f. HLA-compatible platelets
g. Fresh Frozen Plasma when PT/aPTT is <1.5X normal or when >500ml requested
h. Cryoprecipitate
i. Fibrin Glue
j. Antigen-negative red cell units (i.e. patients with clinically significant red cell alloantibodies)
k. In times of suboptimal blood stocks, all blood product requests except for emergency and
MTP cases (BSG will inform SGH Blood Bank Laboratory)
2. The following blood products are available at SGH Blood Bank Laboratory:
a. NSA 5% (Normal serum Albumin)
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b. 20% Human Albumin Solution
c. Factor VIII Concentrate
d. Factor IX Concentrate
e. Factor rVIIa Concentrate
f. Leucocyte Filter for Red Cell Concentrate and Platelets
g. Intravenous Immunoglobulins
Requests can be made directly to SGH Blood Bank Laboratory but, when indications are doubtful,
the ward doctor may be referred to the Haematologist or Head of SGH Blood Bank Laboratory for
further discussion.
3. All blood and blood product requests must be made through a GXM form (Request Form for
Blood and Blood Products) and signed by the requesting doctor. Any subsequent or additional
requests must be accompanied by an appropriately filled and signed new blood request form
even if a phone request has been made. If the doctor wishes to use the earlier request form, he
must fill in the blood/blood product and its amount and sign it before despatching the form to the
SGH Blood Bank Laboratory. The procedures for requesting blood and administration of
blood in the "Guidelines on Administration of Blood and Blood Products" must be strictly
followed.
4. Request for not more than 1 unit of standard adult non-irradiated platelets (pooled platelets or
CSP) can be made directly with SGH Blood Bank laboratory without discussing with the BSG
Medical Officer (provided platelet stocks are optimal) for D-positive patients whose platelet count
is < 20 X 109/L and the last platelet issue is more than 6 hours ago. Besides patient’s name and
NRIC/MRN, such request forms must include patient’s blood group, platelet count and diagnosis.
5. On receiving blood/blood products in the ward, the doctor and nurse must ensure that such
products have been ordered in the CLMM (Closed Loop Medication Management) before
proceeding to the patient's bedside to check the patient's identity.
Written informed consent from patient is required for all elective blood and blood component
transfusion and explained by doctor of the risks of blood transfusion to the patients. The consent is valid
for one admission only. For written informed consent of outpatient blood transfusions, the consent is
valid for one year.
2.10 Massive Transfusion Protocol (MTP)

1. The Massive Transfusion Protocol (MTP) helps to facilitate rapid availability of blood products (red
cells, FFP and platelets) to patients with massive haemorrhage as it has been suggested by
retrospective and observational studies that the early transfusion of FFP and platelets in addition
to red cells helps to improve outcome in these patients.
2. Classical definition of massive haemorrhage is > 50% blood volume loss in 3 hours, > 150 ml blood
loss / min or loss of one blood volume within 24 hours. Activation of the MTP based on clinical
judgment alone or on such criteria can be challenging. Therefore, validated scoring systems such
as the Assessment of Blood Consumption (ABC) score may be more useful in identifying trauma
patients at risk of massive haemorrhage and massive transfusion.
3. Authority to activate the MTP should be restricted to registrars and above. This would be
necessary to minimize inappropriate MTP activation and wastage of blood products so that the
MTP is reserved for patients who are truly in need of this.
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4. Once a doctor with the authority to activate MTP recognises a patient at risk of massive
transfusion, he will call SGH Blood Bank Laboratory (EXT 3666 or 4852) to activate the MTP while
other resuscitative efforts continue. A group and crossmatch sample should be quickly sent to the
blood bank for urgent determination of the blood group (if not done) so that ABO identical blood
products can be issued as soon as possible. While awaiting the blood grouping, O-positive red cell
units will be issued to all patients except Indian and Caucasian patients of child-bearing potential
(who will be given O-negative blood). AB-positive FFP will be issued to all patients.
5. Patients who are already known to be D-negative & who have positive red cell alloantibodies
should be excluded from this MTP protocol. For MTP patients of known D-negative Blood Group,
the team doctor should use the first 2 units of Emergency O negative Blood if necessary (already
available) but also contact the BSG Medical Officer urgently for advice. For patients with known
requirements for rare blood due to clinically significant red cell allo-antibodies, the team doctor
should contact the BSG medical officer immediately to seek advice.
6. Constituents of the MTP Packs are as follows:
Pack 1: - 4 units red cell, 4 units FFP, 1 unit pooled platelets
Pack 2: - 4 units red cell, 4 units FFP, 1 unit pooled platelets
Pack 3: - 4 units red cell, 4 units FFP, 1 unit pooled platelets, with cryoprecipitate (2 pooled units)
(The constituents in each pack are provided as a guide and may be modified to suit the patients’ needs)
The Clinical Team calls the SGH Blood Bank Laboratory directly for release of MTP Packs 1 & 2 and do
not need to call the BSG Medical Officer for approval of MTP Packs 1 & 2 since the standby inventory of
MTP blood products in SGH would be adequate to meet the requirements of the first two packs. The
Clinical Team only needs to call the BSG MO immediately after calling SGH blood bank for delivery of
MTP Pack 2. This is to inform BSG of current MTP activation and potential escalation to MTP Pack 3.
MTP pack 3 may need to be issued from BSG if there are insufficient blood products available in SGH
blood bank laboratory. BSG MO should also be informed when the MTP has ceased or if the MTP needs
to be extended beyond Pack 3, so that arrangements for rapid transfer of additional blood products can
be quickly arranged.
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3. GUIDELINES ON ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS
Doctors, nurses and technicians have a special responsibility to ensure that the samples of blood sent
for grouping and cross matching are fully and correctly labelled and that the recipient is properly
identified before the transfusion is started.
3.1 Indications
1. A transfusion should never be given without a definite indication. This is not in the patient's
interest. Supplies of blood are limited and with the ever-growing demand for blood, it is
important that blood be used judiciously. Transfusion is also associated with potentially serious
risks.
2. Transfusion therapy should only be undertaken after a careful assessment of the patient's clinical
condition. Determine the NATURE and QUANTITY of blood or blood component to be transfused
and the RATE of transfusion.
3. Except in an emergency, no patient should be given blood transfusion unless:
a. The ABO and RhD Groups of the patient and donor blood have been verified,
b. Red cell antibody screening of the patient (and identification of antibodies if screening is
positive)
c. A compatibility test between the patient's serum and the donor's red cells has been done.
3.2 Group and Cross-match

A full group and cross-match blood consists of ABO with RhD blood group typing, antibody screen as
well as cross-match with donor blood.
Due to increased sensitivity of the improved antibody screening using gel technology system
incorporating the 3-cell panel, the current practice is to do the "abbreviated" group and cross-match for
all cases except when the antibody screen is positive. An "abbreviated" group and cross-match
eliminates the antihuman globulin phase in the cross-match with donor blood and reduces it to a rapid
saline match following the antibody screen.
In the type and screen procedure for elective surgery where blood is rarely requested, the antibody
screen is carried out and the rapid saline cross-match with donor blood is done only when the blood is
called for. This allows a more efficient distribution of blood which is a limited commodity.
3.3 Emergency Blood Transfusion

Emergency Group "O" blood which is unmatched should not be used indiscriminately as adverse effects
such as haemolysis due to non-ABO red cell antibodies may occur. It is safer and equally effective in
emergencies to make use of crystalloids or colloids first, followed by plasma, if necessary, and then
matched blood. Usually, Group "O" positive is used as emergency blood for Chinese and Malay patients,
while Group "O" negative should be used for Indian and Caucasian patients, especially females in the
reproductive age groups. The requesting doctor or his representative must telephone the SGH Blood
Bank Laboratory to indicate as ‘URGENT’ for using unmatched emergency Group "O" blood or rapid-
matched blood to ensure its rapid delivery and to take responsibility for its usage even though a request
form has been put up. If the doctor is busy resuscitating a patient, he could assign his nurse to call the
SGH Blood Bank Laboratory on his behalf but he remains responsible for the urgent request. The staff
collecting the blood must be informed of the urgency to avoid any unnecessary delay.
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Categories of blood according to urgency:
 During emergency, unmatched Group “O” positive blood is available upon request (no blood
group match and no antibody screen);
 Rapid-match blood, available in 5 to 10 minutes (with blood group match but no antibody
screen);
 Full-matched blood, available in 25 to 30 minutes (with blood group match and antibody
screen).
3.4 Pre-transfusion Blood Sampling

The following practical points should be carefully observed:
1. For all blood grouping and cross-matching requests, the doctor has to be accompanied by a
nursing staff in the taking of blood sample. It will be the responsibility of the doctor to verify the
name and NRIC/MRN number on the sticky labels with the patient. This should be counter-
checked by the nursing staff assisting the doctor.
2. Immediately after obtaining the blood sample, it will be the responsibility of the doctor to ensure
that the correct sticky labels for the patient are fixed on the blood sample and the GXM form at
the patient's bedside. This should be counter-checked by the nursing staff accompanying the
doctor.
3. The blood sample for compatibility tests must be taken from the correctly identified patient. The
sample must be drawn, labelled and initialled by the doctor at the bedside. The label must have
patient's name and NRIC or MRN number. Draw 5 cc bloods in cross- match container.
4. All data in the GXM form (Request Form for Blood and Blood Products) must be legibly filled in
and signed by the doctor-in-charge. The patient’s labels on the form (all pages) and blood tube
must also be initialled by the requesting doctor. The name and MCR number of the requesting
doctor must be clearly written on the GXM form and the initial/signature on the form must match
that on the patient’s labels. The date and time blood is needed, amount required, location of
patient and surgical procedure and/or diagnosis must be included.
5. Incomplete or improperly labelled specimens and specimens where identification is in doubt will
be discarded by the SGH Blood Bank Laboratory and BSG; a repeat specimen will be required for
the safety of the patient. The correction of improper labels is not permitted. The doctor should
take a new blood sample and certify that he/she has personally taken the blood from the properly
identified patient.
6. Patients with altered mental status or communication problems, who are irrational, patients on
DIL, paediatric patients and whom the Consultant deems transfusion necessary must be tagged to
facilitate patient identification.
7. If the patient is conscious, it is best to verify name, NRIC/MRN and blood group with patient. This
should be confirmed by checking the patient's identification wristband and by confirming it with
patient.
8. A record of every transfusion should be made in the patient's CLMM (Closed Loop Medication
Management). The time of commencement and completion of the transfusion should be noted.
The rate of flow, the patient's pulse rate and temperature should be recorded during the
transfusion and for four hours after completion of the transfusion.
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9. At the SGH Blood Bank Laboratory, the technician should check the patient's previous
transfusion records to verify the blood group and to look for any antibodies detected
previously.
10. On completing the transfusion, all information requested for on the reverse side of the
compatibility label should be carefully filled in. The label should be returned to the SGH Blood
Bank Laboratory within 24 hours of the transfusion. The empty blood pack and transfusion set
must be retained for at least 24 hours after the transfusion, in the event of adverse transfusion
reaction.
3.5 Administration of Blood and Blood Products

Before starting a transfusion, 2 medical staff (doctors and/or nurses) must ensure that the written
consent is up and there is proper blood prescription before checking each bag of blood at the patient's
bedside to ensure that:
1. The patient’s name, date of birth, gender and NRIC number indicated on the compatibility label
attached to the blood pack are the same as the patient's particulars on the patient's wrist
identification and GXM form. These should also be verified personally with the patient whenever
possible. Verification of the patient's identity and checking of blood unit must be done at the
patient's bedside by two separate persons – preferably one doctor and another staff nurse;
however, if no doctor is available, the blood can be checked by 2 staff nurses. They must
acknowledge this by signing on the blood compatibility label just before transfusion is set up. Set
up the blood unit immediately after it has been checked.
2. The number on the blood pack and blood grouping are to be the same on both the compatibility
label and blood bag before administering a transfusion. In addition, patient’s blood group should
also be verified with the patient whenever possible.
3. Many incompatible transfusion disasters have occurred through neglect of the above practices.
4. Any discrepancies in the compatibility label, blood unit and/or GXM form should not be corrected
but to return to the Blood Bank Laboratory immediately.
5. The ultimate responsibility for ensuring proper patient identification for a blood transfusion lies
with the medical staff responsible for setting up the transfusion.
6. A record of every transfusion should be made in the patient's medication records on CLMM.
The following precautions should be taken:
1. The blood or blood component must be carefully examined before it is transfused to try to detect
abnormalities, which would make it unsuitable for transfusion, e.g., haemolysis, infection,
clotting, or evidence that the bag has been breached.
2. In routine transfusions, whole blood and red cell concentrates may be administered without the
need to warm the blood prior or during the transfusion. Warming may be necessary in certain
situations such as neonatal exchange transfusion, presence of clinically significant cold agglutinins
or when large volumes are given rapidly, i.e., at rates > 50 ml/kg/hour. In these cases, blood
should only be warmed as it passes through the infusion set. Use of uncontrolled equipment is
discouraged as excessive warming may lead to haemolysis.
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3. Blood should be drawn from the blood bank only when required and should not be stored in a
refrigerator in which the temperature is not carefully controlled (e.g., domestic refrigerator). It is
dangerous to draw blood from the bank and then return it unused for further storage after a
period in the ward because it may not have been stored satisfactorily during this period. Because
blood at 1°C to 6°C warms to 10°C or above in approximately 30 minutes at room temperature,
transfusion should either be started or the unit returned to the blood bank within 30 minutes.
4. Blood and components must be transfused through standard blood filters designed to retain
blood clots and other debris.
5. In general, blood should not be transfused through infusion sets used for other fluids. Some may
cause haemolysis (e.g., 5% dextrose in water) and others clotting (e.g., Ringer's lactate). Only
normal saline (sodium chloride 0.9 g/dl) may be used for flushing infusion sets for blood
transfusion. No medication or intravenous solutions other than normal saline may be added to
blood or components.
6. Flow at high pressure or through small-gauge needles may damage red cells. For infusing whole
blood or red cells, an 18- or 19-gauge needle gives good flow rates without excessive discomfort
for the patient. For patients with small veins, much smaller needles must be used. Blood flows
very slowly through needles smaller than 23-gauge, and applying excessive external pressure to
speed infusion may damage the cells. Whole blood or red cell concentrates should be
administered slowly during at least the first half hour, and a close watch kept on the patient for
the earliest signs of a transfusion reaction. The nurse must observe the patient closely for 5 mins
at the start of the transfusion. The pulse rate, temperature, blood pressure and respiratory rate
should be taken and documented before the start of transfusion and repeated 10 minutes and 30
minutes after the start. The volume and rate are then regulated as appropriate to patient’s
condition to prevent circulatory overload. The rate of flow, pulse rate and temperature,
venepuncture site and potential adverse reactions should be monitored and observed hourly
during the transfusion and for 4 hours after completion of the transfusion. Because of the risk of
bacterial infection or deterioration of the blood components when they are exposed to room
temperatures, transfusion of each unit should not take more than four hours. Some blood
components should, however, be given more rapidly. For e.g. 1 adult therapeutic dose of platelets
over about 30-60 minutes, 1 unit of FFP over 30 minutes, 1 unit of pooled cryoprecipitate (from 5
donors) over 30-60 mins. The time of administration and the volume of each component
administered should be recorded.
7. If any adverse blood transfusion reaction occurs, the transfusion should be stopped
immediately. The SGH Blood Bank Laboratory should be notified whenever a transfusion reaction
of any kind has occurred. All reactions must be appropriately investigated fully to determine the
cause.
8. All adverse blood transfusion reactions must be reported through the hospital Risk
Management System (RMS).
9. The SGH Blood Bank Laboratory must be notified in the event that the patient develops an
infection or other complications, which is likely to have been caused by the transfusion. Any
further requests for blood or blood products prior to the completion of the investigations for
transfusion reactions should be made in consultation with the BSG doctor.
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4. ABO GROUP OF BLOOD COMPONENTS COMPATIBLE FOR TRANSFUSION
(NOT APPLICABLE FOR ABO-INCOMPATIBLE TRANSPLANT PATIENTS)*
ABO Group Compatible for Red Cell Transfusion
Component’s ABO Group
Patient’s ABO Group
Red cell concentrate Whole blood
A A, O A
B B, O B
O O O
AB AB, A, B, O AB
RhD negative patients should receive RhD negative red cell concentrate or whole blood (except in emergency
when RhD negative blood is unavailable AND patient has no anti-D)
ABO Group Compatible for Plasma Transfusion

Patient’s ABO Group Component’s ABO Group
A A, AB
B B, AB
O O, A, B, AB
AB AB
RhD status not necessary in ABO selection of PLASMA as red cell content is low in plasma
ABO Group Selection for Platelet Transfusion (Adult patients)

Component’s ABO Group
Patient’s (selection by Blood Service and Blood Bank depending on availability)
ABO Group
1st choice 2nd Choice 3rd Choice 4th Choice
A A AB B O
B B AB A O
O O A or B A or B AB
AB AB A B O
RhD negative patients receiving RhD positive platelets should be given RhD immunoglobulins (eg. Rhogam),
especially in females with child bearing potential
ABO Group Compatible for Platelet Transfusion (Neonatology patients)

Patient’s ABO Group Component’s ABO Group
A A, AB
B B, AB
O O, A, B, AB
AB AB
RhD negative patients receiving RhD positive platelets should be given RhD immunoglobulins (eg. Rhogam),
especially in females with child bearing potential
*For haematopoietic stem cell transplant patient, please refer to patient’s form on “Blood
Group Selection for Blood Products in Haematopoietic Stem Cell Transplant Patients”.
*For ABO incompatible renal transplant patient, please refer to “Kidney Transplant Handbook”
(available on Renal Transplant Folder of SGH Infonet).
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5. REPLACEMENT CLOTTING FACTOR TREATMENT FOR HAEMOPHILIA
5.1 Factor Concentrate level guidelines

No. Severity of Bleeding Type of Bleeding Level desired
• Minor or single joint bleeding

• Muscle bleeding
1 Mild Bleeding • Epistaxis 30%
• Dental bleeding
• Haematuria
• Major or multiple joint bleeding

• Neck, tongue, pharynx bleeding (without
2 Moderate Bleeding * 50%
airway compromise) Abdominal bleeding
• Head trauma without neurological deficit
• Intracranial bleeding
• Major operation Major trauma
3 Severe Bleeding * Compartment syndrome 75 - 100%
• Neck, tongue, pharynx bleeding (with
airway compromise)
* Patient has to be admitted and factor concentrates may be given 12 hrly.
5.2 Haemophilia A
1. Without Inhibitors
1 unit/kg Factor VIII will raise plasma level of Factor VIII by 2%.
1 vial of factor VIII = 250 IU.
E.g. If patient weights 65kg and you want to raise to 30% factor level,
 Factor VIII unit = 65 x 30/2
 975 IU needed
 Number of vials = 975 / 250 4 vials to be given as slow bolus (can order for 1-2 days)
2. With Inhibitors (< 5 BU)

Will need to give Factor VIII for both swarming and maintenance, i.e.,
a. For swarming, e.g. 3 BU of inhibitors in 65 kg patient,
 0.7 x 40 x Wt in kg x inhibitor level (plasma volume = 40ml/kg, constant factor = 0.7)
 0.7 x 40 x 65 x 3 = 5460 BU
 Number of vials = 5460 / 250 = 22 vials
b. For maintenance, e.g. to raise to 50 % factor level,
 Unit of factor VIII = 65 x 50/2 = 1625 IU
 Number of vials = 1625 / 250 7 vials
c. Therefore, total vials needed = 22 + 7 = 29 vials
Above infusion can be given by continuously.

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3. With Inhibitors (> 5 BU)
Suspect inhibitors if sufficient factor concentrates had been given and bleeding is still not arrested.
To arrest bleeding, options available are:
a. Factor IX bypass
 Not very effective
 Relatively cheaper
 Dose = usually about 2-3 vials for 65kg adult
b. Factor VIIa
 Effective
 Expensive
 Dose = 60 - 120 mcg / kg
 3 vials for 65 kg patient per dose everyday 4 - 12 hrly (max. 3 doses)
c. FEIBA
 Sometimes effective
 Expensive
 Dose = 50 - 100 IU/kg per dose, 2-3x / day for 1 - 2 days
5.3 Haemophilia B
≈ 1 unit/kg Factor IX will raise plasma level of Factor IX by 1%.
1 vial of factor IX 500 IU.
E.g. If patient weights 65 kg and you want to raise to 30% factor level,
 30 x 65
 1950 IU needed
 Number of vials = 1950 / 500 = 4 vials to be given as slow bolus
Factor IX concentrate is not absolutely pure, overdose can cause paradoxical thrombosis especially in
patients requiring > 30% factor level (ie moderate or severe patient).
Information on Haemoglobulin patient's previous history and inhibitor status as well as assistance in the
management of Haemophilia may be obtained from the Senior Staff Nurse at the National
Haemophilia Registry SGH, Tel: 6321 3844.
Haemophilia patients with inhibitor are difficult to treat and should be managed by the Haematologist.
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6. STORAGE OF BLOOD AND BLOOD COMPONENTS
6.1 Storage of Whole Blood and Red Cell Concentrates

1. Whole blood and packed red cells should be stored between 2°C and 6°C.
2. Blood should be stored in a blood bank refrigerator that has been specifically designed for the
purpose. This includes blood that is kept in sites outside the blood bank, such as operating theatre
and DEM (department of emergency Medicine).
3. The refrigerator should have a built-in temperature sensor connected to a recording chart that
monitors the equipment continuously. There should also be an alarm system with an audible
signal that activates before the blood units reach unacceptable storage temperatures. The
electrical source for the alarm system must be separate from that of the refrigerator to ensure
that the alarm will not be cut off when there is a power failure.
4. Blood units should be arranged so that the oldest blood is within easy reach and is used first.
6.2 Storage of Fresh Frozen Plasma and Cryoprecipitate

1. Thawed, fresh-frozen plasma used for correction of labile coagulation factor deficiencies should
be stored between 2°C and 6°C and infused within 24 hours after thawing. Thawed units should
not be re-frozen.
2. Pooled cryoprecipitate should be stored at room temperature (20°C to 24°C) until transfusion,
and should be administered within 6 hours of thawing (for pooled cryoprecicipate) and 4 hours of
open pooling. Thawed units should not be re-frozen.
6.3 Storage of Platelets

1. Platelet concentrates should be stored between 20°C and 24°C.
2. Continuous gentle agitation is essential.
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7. TRANSPORTATION OF BLOOD AND BLOOD PRODUCTS
Issue of whole blood (WB) and red blood cells (RBC) from the blood bank laboratory to other parts of
the hospital must be controlled so that unused blood is returned within a set period of time. Because
blood at 2°C to 6oC warms to 10°C or above in approximately 30 minutes at room temperature,
transfusion should either be started or the unit returned to the blood bank within 30 minutes.
When blood is issued for transfusion, it should not be allowed to remain unnecessarily long at room
temperature. Delayed delivery to the patient, delayed arrival of personnel to begin transfusion and
delays during infusion should be avoided.
If a slightly longer time must elapse before transfusion, individual units may be placed in a sturdy, well
insulated container that maintains the appropriate temperature.
Blood (RBC and WB)
 Temperature must be kept at 1°C to 10°C during transportation.
To transport using sturdy, well-insulated shipping containers with adequate cooling materials
(chemical coolant pack)
 The coolant should be separated by a plastic divider (corrugated plastic boards) from the blood
packs to avoid direct contact with the blood packs
 Storage temperature must be between 2°C and 6°C.
 Blood must never be stored in unmonitored refrigerators.
Thawed Fresh Frozen Plasma (FFP)
 Thawed FFP used for correction of labile coagulation factor deficiencies should be stored at 2°C
to 6oC and be infused within 24 hours after thawing.
 Temperature must be kept at 1°C to 10°C during transportation.
Platelets
 Store between 20°C and 24°C with continuous gentle agitation.
 Temperature to be maintained between 20 and 24°C during transportation. A well-insulate
container without added ice is often sufficient.
Granulocytes
 Store between 20°C and 24°C (up to 24 hours).
 Best to transfuse them as soon as possible after collection as studies have shown that after 8
hours of storage, granulocytes have reduced ability to circulate and migrate to a site of
inflammation.
Plasma derivatives (including Recombinant Factor 7a) should be stored according to the manufacturers’
recommendation. As a general rule, they are usually stored at the following temperatures:
 FEIBA: 2°C to 8°C
 Factor 7a (Novoseven): 2°C to 8°C
 Factor 8: 2°C to 8°C
 Factor 9: 2°C to 8°C
 Immunoglobulin (IVIG): 2°C to 8°C
 5% Human Albumin: 2°C to 25°C
 20% Human Albumin: 2°C to 25°C
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8. TRANSFUSION HAZARDS AND REACTIONS
1. Potential hazards of transfusion are such that there must be proper indication before
administering any blood components.
2. Transfusion reactions may be classified as:
a. Febrile Non-Haemolytic Transfusion Reaction
b. Allergic or Hypersensitivity Reaction (include 25rticarial)
c. Anaphylatic Reaction
d. Acute Haemolytic Transfusion Reaction
e. Delayed Haemolytic Transfusion Reaction
f. Incorrect Blood Components Transfused
g. Transfusion Associated Graft Versus Host Disease
h. Transfusion Related Acute Lung Injury
i. Post Transfusion Purpura
j. Transfusion Transmitted Infections (include bacteria contamination)
3. If a transfusion reaction is suspected, stop the transfusion but keep the vein open with an
intravenous infusion.
4. Inform the SGH Blood Bank Laboratory immediately. All transfusion reactions must be reported
through the hospital RMS. The completed form from the RMS should be printed out and sent to
SGH Blood Bank Laboratory, accompanied by a post-transfusion sample of recipient blood, the
blood pack and administration set. A second blood sample must be taken 24 hours after the first
specimen. All post-transfusion reaction blood samples should be personally taken and labelled by
the DOCTOR-IN-CHARGE.
5. Monitor the patient’s vital signs (pulse rate, BP) and urine output.
6. All transfusion reactions have possible medico legal implications. Doctors and ward staff should
therefore take particular care when dealing with a case of transfusion reaction to ensure that all
forms and reports are carefully kept. The time and onset of all clinical symptoms should be
carefully documented.
7. No further transfusion of blood or blood products should be carried out without checking the
results of the transfusion reaction investigations especially for any evidence of haemolysis from
incompatibility of blood. Always consult the BSG doctor or Haematologist-on-call if there is any
doubt or if urgent transfusion of blood or blood component is required.
8. If the antibody screening test is positive or if there is any evidence of antibody, BSG doctor must
be informed before any further issuing of blood or blood products.
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9. AUTOLOGOUS BLOOD DONATION FOR ELECTIVE SURGERY
Definition
What is Autologous Blood Transfusion?
Autologous Blood Transfusion (ABT) is a procedure where a person donates blood or blood products
which are transfused back to him at a later date, e.g. during or after surgery. It helps to alleviate some of
the adverse effects associated with allogeneic blood transfusion such as red cell alloimmunisation and
transfusion-transmitted infections (except bacterial infections) provided that the autologous blood is
transfused to the correct patient. With more patients using autologous blood transfusion for planned
surgery, the Blood Bank will be able to keep more reserves of blood available for emergencies. There are
three types of ABT:
1. Pre-surgical donation and storage
2. Acute normovolaemic haemodilution and short term storage
3. Intra-operative blood salvage and re-transfusion
9.1 Pre-surgical donation and storage

 This procedure is particularly appropriate for rare blood types and certain types of elective
surgery with anticipated significant probability of requiring red cell transfusion.
 No lower age is provided for autologous blood donation provided that parental consent has
been taken and patients are cooperative.
 At SGH (ABC), patient's blood is collected and can be stored up to five weeks (35 days) before its
expected use.
 Depending on how much blood will be needed, patient's blood can be collected up to once
every week.
 Last unit of blood donation should be at least 72 hours before the planned surgery
 Avoid taking out blood too early (e.g., more than three or four weeks before operation) as the
blood may expire if the operation is postponed.
 The "Request Form for Autologous Blood Donation" is available at the Specialist Outpatient
Clinic and SGH Blood Bank Laboratory.
9.2 Acute normovolaemic haemodilution (ANH) and short term storage

 Blood is collected and simultaneously replaced with haemodiluent (e.g. normal saline) in the
operating theatre by the Anaesthetist just prior to surgery and intravenous fluids are given to
replace the volume.
 Intravascular volume is maintained with a lower haematocrit level. As a result, blood loss during
surgery has lower haematocrit.
 Transfusion option for the patient who can tolerate acute decrease in haematocrit (ideally
haematocrit < 0.30)
 Blood collected can be stored for use up to 24 hours (refrigerated at 4°C after surgery). The
blood is then transfused back to the patient during or after surgery.
 This method is suitable for surgery where there is a large amount of blood loss, e.g. open heart,
vascular, chest and spinal surgery.
 Alternative for the patient who is not suitable for presurgical blood donation, e.g. surgery is
required on short notice.
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Advantages:
1. Avoids potential for transfusion-transmitted infections
2. Avoids potential for transfusion reactions related to allogeneic transfusion of blood and blood
products.
3. Avoids potential for immunomodulatory effects.
4. Provides the only source of fresh whole autologous blood. e. No "storage lesions".
5. RBC loss is reduced (Hct is lowered).
6. Potential improvement of tissue perfusion (reduced viscosity).
Logistic Advantages:
1. May be done for patients under urgent or emergency circumstances that preclude a planned, pre-
donation schedule.
2. Patients with systemic disease may undergo ANH while intensively monitored in the Operating
Theatre.
3. The presence of malignancy or wound infection may contraindicate intra-operative blood salvage
but not ANH.
Indications:
1. Surgical procedures in which blood loss of more than 1000 ml is anticipated.
Contraindications:
1. Anaemia - Usually inappropriate to use ANH where the pre-operative Hb is less than 11g/dL
2. Reduced renal function - Infused diluent fluids may not be adequately excreted.
3. Inability to increase coronary blood flow - Severe aortic stenosis or coronary artery stenosis
(however, in selected cases, under intensive monitoring in the cardiac operating theatre, ANH
may be performed for some patients prior to CABG).
4. Severe carotid artery disease.
5. Pulmonary disease-impairing oxygenation.
6. Inadequate vascular access.
7. Inadequate monitoring facilities.
Technique:
1. Monitor:
 ECG
 Intra-arterial blood monitoring
 Central venous pressure monitoring
 Pulse oximetry
 Urinary catheter
 Serial haematocrit
2. Volume to be withdrawn
V = EBV x (Ho - Hf) Hav
V =Volume to be withdrawn
EBV = Patients' estimated volume
Ho = Initial Hct
Hf = Final (minimal allowable) Hct
Hav = Average Hct
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4. Blood is withdrawn from a large vein and collected in standard blood bags and labelled
"Immediately" and kept in the same operating theatre. Bags should be weighed to ensure
appropriate amount of blood relative to anticoagulant.
5. Crystalloid or colloid or both, are infused as blood is withdrawn:
 Volume of crystalloid is three times the volume of blood removed.
 Volume of colloid is 1:1.
6. Labelling
 Name.
 Hospital Registration / NRIC Number.
 Time of removal of blood.
 Units should be labelled sequentially.
7. Handling of blood units:
 Kept in the same OT.
 Kept in the same box at room temperature unless more than eight hours-time lapse is
anticipated before re-infusion.
 Refrigerated units of more than 24 hours should be discarded.
 Re-infusion Protocol:
o Re-infusion after major blood loss has ceased or sooner if indicated.
o Re-infusion in reverse order of collection so that the first unit, having the highest Hct
and the most clotting factors, is administered last.
8. Minimal Safe Haematocrit:
 This depends on the patient's ability to compensate for the decrease in arterial oxygen
contact. Generally, this should be less than 20-25%.
9.3 Intra-operative blood salvage and re-transfusion

 Blood lost during surgery is collected, processed and returned to the patient during the
surgical procedure by a blood cell saver.
 Suitable for procedures where:
o Anticipated blood loss is more than 20% of blood volume
o At least 10% of patients undergoing such procedures need transfusion
o Mean transfusion per patient for the procedure is more than two units.
 Appropriate for clean surgical procedures, e.g. open heart, vascular, total joint replacement
and spinal surgery, liver transplant, etc.
 Ensures the immediate availability of large amounts of blood for transfusion when there is
massive bleeding, e.g. ruptured ectopic pregnancy, intra-abdominal or chest-trauma.
 Not suitable if procedure involves contaminated bleeding sites, or areas of malignancy or
infection at operative site.
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10. USING SGH AUTOLOGOUS BLOOD CLINIC (ABC)
10.1 Advantages of Pre-Surgical Autologous Blood Donation

1. No risk of acquiring transfusion transmitted infections
(Does not eliminate risk of bacterial sepsis relating to blood transfusion)
2. No risk of allo-immunisation to cellular and plasma protein antigens.
3. Immediate availability of "compatible blood" when compatible blood may not be available, or
delayed availability (intra-operative salvage): useful in patients with rare blood group or red cell
alloantibodies to common red cell antigens
4. Decreased demand on the homologous blood supply.
10.2 Criteria for Acceptance on Pre-Surgical Autologous Blood Donation

1. Age < 70 years (with parental consent if < 18 years old).
2. Weight more than 25 kg.
3. Haemoglobin of at least 11 g/dL regardless of sex.
4. No severe respiratory, cerebrovascular or CVS diseases.
5. No severe uncontrolled hypertension or hypotension
6. No active sepsis or risk factors for bacterial infections (Skin at venepuncture site in the antecubital
fossa should be free from skin lesions)
7. No history of epilepsy.
8. No history or risk factors for Hepatitis B, C, HIV, syphilis and other sexually transmitted infections
and transfusion transmitted infections
9. Not absolutely contraindicated in pregnancy.
10. Not contraindicated in patients on medication.
10.3 How to Schedule

1. Select suitable donor-patients for the presurgical deposit donations. In general, patients who are
fit to undergo major elective procedures are suitable for ABT. These operations would include
cholecystectomy, hysterectomy, haemorrhoidectomy and thyroidectomy. The medical staff at
ABC will make a final assessment to ensure that your patient is suitable for ABT.
2. Discuss with your surgical and anaesthetic team regarding the possible use of intra-operative
haemodilution and intra-operative blood salvage procedures.
3. Obtain the written consent of the patient
 Explain the procedure, its advantages and the possible problems associated with autologous
blood donation and transfusion. Possible problems include situations when blood collected
 cannot be used, e.g., when it tests positive for infectious disease, if the blood pack bursts
during processing, when the operation is postponed and the blood becomes outdated. Very
rarely, patients may experience giddiness or fits after donation.
 As the referring doctor, it is your responsibility to obtain a written consent from your
patient before referring him to SGH Autologous Blood Clinic.
 If your patient is a minor, written consent must be obtained from his parent or guardian.
 Use your hospital’s Consent Form for Surgical Procedures.
4. Make an appointment with SGH Autologous Blood Clinic for autologous blood collection.
 To be referred to SGH Autologous Blood Clinic, your patient will need to bring:
 A written consent signed by the doctor in charge
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 A written consent signed by the patient or his parent/guardian
 NRIC for Singaporeans and passport for foreigners
5. Give your patient iron supplements
 Start your patient on oral iron supplements one week before the first blood collection and
continue this for three months after the last donation.
 The usual adult dose for ferrous sulphate is 325 mg three times a day to be taken with meals
to prevent gastric upset.
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11. USING THE SGH BLOOD BANK LABORATORY
The SGH Blood Bank Laboratory maintains a 24-hour service. Only emergency requests will be dealt with
after office hours and on Sundays and public holidays.
All cases scheduled for surgery in which it is likely that blood would be required should have the blood
sent to the SGH Blood Bank Laboratory for cross-matching one day before the date scheduled for the
operation.
The normal cross-match or compatibility test procedure takes less than half hour but allow one to two
hours for non-urgent cases. If blood is required urgently, the appropriate box on the Blood Request
Form should be ticked off.
Doctors should telephone to inform the laboratory when the blood is urgently required. Unless this is
done, the request will be treated like any other non-urgent request.
Cross-matched blood will be kept in reserve for only 24 hours. If not used within this time, it will be re-
circulated. If blood is required to be kept in reserve for more than 24 hours, the doctor-in-charge should
inform the laboratory accordingly.
Topping up haemoglobin with red blood cell transfusion should be discouraged after 2000 hours, if
patient is stable.
There is a Medical Officer on-call throughout 24 hours at BSG. The on-call M.O. can be contacted at
9186 4133.
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12. GUIDELINES FOR THE PROCUREMENT OF BLOOD FOR ELECTIVE SURGERY
1. All elective surgery requiring blood should be listed in the OTM one day before the operation.
2. The cut-off time for the listing is at 1500hr (Monday to Thursday) and at 1200hr (Sundays and
Public Holidays).
4. Add-on or amended cases listed in the OTM after 1500hr on weekdays or 1200hr on Sundays and
Public Holidays will only be confirmed after 0900hr on the following day.
5. SGH Blood Bank will update all blood approvals by 2000hr on the day before the surgery. The late
or amended blood requests will be updated by 0900hr on the day of surgery.
6. SGH Blood Bank will indicate the number of blood units approved for each patient in the OTM
listing, except for cases pending the cross-match specimen. For such cases, the blood availability
will only be confirmed when the cross-match specimens are received. Both the ward and
operating theatre staff can view the OTM inquiry screen for blood availability for all elective
cases.
7. SGH Blood Bank will update additional comments for patients with abnormal red cell
antibodies pending identification or when patient has a rare blood type, such as D-negative.
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Blood Transfusion Guideline: 6 Edition

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What are the guidelines for red blood cell transfusion in patients with persistent chronic anemia?

What are the guidelines for red blood cell transfusion in patients with persistent chronic anemia?

What are the guidelines for red blood cell transfusion in patients undergoing surgery?

What are the guidelines for red blood cell transfusion in patients undergoing surgery?

6th Edition

Blood Transfusion Guideline

CHAIRMAN MEDICAL BOARD

SINGAPORE GENERAL HOSPITAL

SGH Blood Transfusion Guideline (6th Edition) Page 3

A/PROF TIEN SIM LENG CHAIRMAN

SGH BLOOD TRANSFUSION COMMITTEE

2.1 Red Cell Transfusion in Acute Blood Loss

Guidelines for Red Cell Transfusion during Acute Blood Loss

SGH Blood Transfusion Guideline (6th Edition) Page 6

2.2 Other Circumstances when Red Cell transfusion may be needed

SGH Blood Transfusion Guideline (6th Edition) Page 7

 Enhancement of general sense of well-being.

Guidelines for Red Cell Transfusion in patients going for operations

Pre-Operative Blood Transfusion

SGH Blood Transfusion Guideline (6th Edition) Page 8

Post-Operative Blood Transfusion

Additional Requirements of Red Blood Cells

2.3 Platelets Transfusion

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2.4 Fresh Frozen Plasma Transfusion

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2.5 Cryoprecipitate Transfusion

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2.7 Intravenous Immunoglobulin Transfusion

2.8 Plasma Substitutes Transfusion

2.9 Further Guidelines for Ordering Blood and Blood Products

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2.10 Massive Transfusion Protocol (MTP)

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3.2 Group and Cross-match

3.3 Emergency Blood Transfusion

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3.4 Pre-transfusion Blood Sampling

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3.5 Administration of Blood and Blood Products

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ABO Group Compatible for Plasma Transfusion

ABO Group Selection for Platelet Transfusion (Adult patients)

ABO Group Compatible for Platelet Transfusion (Neonatology patients)

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5.1 Factor Concentrate level guidelines

• Minor or single joint bleeding

• Major or multiple joint bleeding

2. With Inhibitors (< 5 BU)

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6.1 Storage of Whole Blood and Red Cell Concentrates

6.2 Storage of Fresh Frozen Plasma and Cryoprecipitate

6.3 Storage of Platelets

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