🩸Red Blood Cells (RBCs)
Packed Red Blood Cells (pRBCs)
- Volume: ~250–350 mL per unit
- Haematocrit: 55–75%
- Storage: 1–6°C, standard shelf life 35–42 days (depends on additive solution: SAG-M/ADSOL)
- Each unit raises Hb by approximately 10 g/L in a 70 kg adult
- Must be used within 4 hours of removal from controlled storage
Modified RBC Products
- Leucodepleted: <5×106 residual WBCs. Reduces febrile reactions, CMV transmission, and HLA alloimmunisation. Now universal standard in most GCC and UK countries.
- Irradiated: Gamma or X-ray irradiation prevents transfusion-associated GvHD. Required for: immunocompromised, neonates, directed donations, HLA-matched products, Hodgkin lymphoma, post-SCT.
- CMV-negative: For CMV-seronegative immunocompromised patients, neonates, and CMV-negative pregnant women. Leucodepletion is considered equivalent by many guidelines.
- Washed RBCs: Removes plasma proteins — used in IgA deficiency with anti-IgA antibodies or severe allergic reactions.
🟡Platelets
Types
- Pooled platelets: Derived from 4–6 whole blood donations. Adult therapeutic dose.
- Apheresis (single-donor) platelets: One donor, equivalent dose, lower alloimmunisation risk, preferred when HLA matching needed.
- HLA-matched platelets: For patients with HLA antibodies causing platelet refractoriness.
Indications
- Prophylactic: platelets <10×109/L (stable); <20×109/L if fever/antibiotics
- Pre-procedure: <50×109/L (minor); <100×109/L (neurosurgery/eye)
- Active bleeding with thrombocytopaenia
Storage & Safety
- Temperature: 20–24°C with continuous gentle agitation
- Shelf life: 5–7 days (longer with pathogen inactivation)
- Bacterial contamination is the leading infectious risk (Staphylococcus, Gram-negative organisms)
- Must be ABO-compatible where possible; Rh(D) compatibility important in females of childbearing potential
- Pathogen inactivation technology (Intercept, Mirasol) increasingly used
Key RiskBacterial sepsis risk is higher with platelets than any other blood component due to room-temperature storage. Inspect the unit: do not use if turbid, clumped, or swirling is absent.
🟠Fresh Frozen Plasma (FFP)
Key Facts
- Contains all clotting factors (including labile V & VIII) at ~1 IU/mL
- Volume: ~250–300 mL per unit
- Storage: -25°C or below, shelf life up to 2 years
- Thaw at 30–37°C (water bath or approved thawer) — takes ~30 min
- Once thawed: use within 4 hours (24h if stored at 2–6°C as "thawed FFP")
- Dose: 10–15 mL/kg
ABO Compatibility
- ABO compatibility REQUIRED (contains anti-A and/or anti-B antibodies)
- Group AB FFP is universal donor
- Rh(D) compatibility not required for FFP
Indications
- Replacement of multiple clotting factor deficiencies (e.g., liver disease, massive transfusion)
- DIC with active bleeding
- TTP (Thrombotic Thrombocytopaenic Purpura) — plasma exchange
- Warfarin reversal when PCC unavailable and haemorrhage present
- Rare factor deficiencies lacking specific concentrate
Not Indicated For
- Volume expansion alone
- Nutritional support
- Prophylactic use for elevated PT/APTT without bleeding
- Replacement of immunoglobulins
❄️Cryoprecipitate
Composition (per unit)
- Fibrinogen (~150–300 mg) — primary use
- Factor VIII (~80–100 IU)
- von Willebrand Factor (vWF)
- Factor XIII
- Fibronectin
Adult dose: typically 2 pools (10 units). Use within 4h of thawing. ABO compatibility not strictly required but preferred.
Indications
- Massive haemorrhage — fibrinogen <1.5 g/L (target >2 g/L in obstetric haemorrhage)
- DIC with low fibrinogen
- Hypofibrinogenaemia (congenital or acquired)
- vWD and Factor VIII deficiency when concentrates unavailable
- Uraemic bleeding (adjunct)
Fibrinogen target in PPH: Maintain fibrinogen >2 g/L; early cryoprecipitate reduces mortality in obstetric haemorrhage (WOMAN trial data).
💊Prothrombin Complex Concentrate (PCC)
Contains
- 4-factor PCC: Factors II, VII, IX, X + Proteins C & S
- 3-factor PCC: Factors II, IX, X (lower FVII)
Indications
- Warfarin reversal — life-threatening haemorrhage or urgent surgery (with IV Vitamin K)
- Direct oral anticoagulant (DOAC) reversal where specific antidote unavailable
- Liver disease with active haemorrhage
Advantage over FFP: Small volume, faster preparation (no thawing), superior INR reversal. Preferred over FFP for warfarin reversal.
💧Albumin Solutions
Types
- 4.5% (iso-oncotic): Volume expansion — similar osmotic pressure to plasma. Used in SBP, large-volume paracentesis (>5L), hepatic failure.
- 20% (hyperoncotic): Mobilises oedema fluid from interstitium. Burns (after 24h), severe hypoalbuminaemia.
Key Indications
- Spontaneous bacterial peritonitis (SBP) — 1.5 g/kg day 1, 1 g/kg day 3
- Large-volume paracentesis >5L (8 g/L ascites removed)
- Major burns (after first 24h)
- Plasma exchange
🔬ABO & Rh Blood Group Systems
| Blood Group | RBC Antigens | Serum Antibodies | Can Receive From | Can Donate To |
|---|---|---|---|---|
| A | A | Anti-B | A, O | A, AB |
| B | B | Anti-A | B, O | B, AB |
| AB | A and B | None | A, B, AB, O (universal recipient) | AB only |
| O | Neither | Anti-A and Anti-B | O only | A, B, AB, O (universal donor) |
Rh System
- Rh(D) positive: D antigen present (~85% of population)
- Rh(D) negative: D antigen absent; can develop anti-D after exposure
- Rh(D) negative females of childbearing age: must receive Rh(D) negative blood and anti-D immunoglobulin after sensitisation events
- Other Rh antigens: C, c, E, e — clinically significant in multiply transfused patients
Antibody Formation
- Naturally occurring: Anti-A, Anti-B (form without RBC exposure)
- Immune (alloantibodies): form after exposure via transfusion or pregnancy (e.g., anti-D, anti-K, anti-Jka)
- Autoantibodies: Directed against own RBC antigens — seen in autoimmune haemolytic anaemia (AIHA)
- Alloantibody screen (antibody screen) detects clinically significant antibodies
Emergency O negative blood: Used when group is unknown and transfusion cannot wait. O negative blood should be conserved as it is in limited supply — switch to group-specific blood as soon as crossmatch available.
📋Transfusion Indication Assessment
Haemoglobin Transfusion Thresholds (RBCs)
| Patient Group | Transfusion Threshold (Hb) | Target Post-Transfusion |
|---|---|---|
| Most stable inpatients | <70 g/L | 70–90 g/L |
| Acute coronary syndrome / cardiac surgery | <80 g/L | 80–100 g/L |
| Symptomatic elderly / patients with cardiorespiratory disease | <80–100 g/L (clinical judgement) | 90–100 g/L |
| Critical illness (ICU) — TRICC criteria | <70 g/L (unless haemodynamically unstable) | 70–90 g/L |
| Haematological malignancy / chemotherapy | <70–80 g/L (institutional policy) | 80 g/L |
| Chronic anaemia (e.g., thalassaemia) | Pre-transfusion Hb per programme protocol | Hb 90–100 g/L |
| Acute haemorrhage with haemodynamic compromise | Clinical decision — do not wait for Hb result | — |
Restrictive strategy: Evidence (TRICC, FOCUS, TRACS trials) supports restrictive transfusion thresholds in most patients. Transfusion is not without risk and should only be used when clinically indicated.
🔄Patient Blood Management (PBM)
PBM is a patient-centred, multidisciplinary, evidence-based approach to optimise clinical outcomes by managing and preserving the patient's own blood. WHO endorses PBM globally.
Pillar 1: Optimise
Identify and treat anaemia pre-operatively: IV iron (ferric carboxymaltose), EPO in selected patients, treat underlying cause (B12, folate, iron deficiency). Target Hb >130 g/L before elective surgery.
Pillar 2: Minimise Loss
Cell salvage (intraoperative/postoperative), meticulous surgical haemostasis, avoid over-phlebotomy, minimise sample volumes, antifibrinolytics (TXA), minimally invasive surgery.
Pillar 3: Optimise Tolerance
Tolerate physiological anaemia: supplemental O2, cardiorespiratory optimisation, restrictive transfusion thresholds, identify high-risk patients early, goal-directed fluid therapy.
Alternatives to Allogeneic Transfusion
- Autologous pre-donation: Patient donates own blood before elective surgery (limited use now)
- Cell salvage: Intraoperative red cell recovery and re-infusion
- Iron infusion: IV iron sucrose/ferric carboxymaltose for pre-op iron deficiency anaemia
- Recombinant EPO: Renal anaemia, pre-operative in selected patients
- Tranexamic acid (TXA): Antifibrinolytic — proven mortality benefit in trauma (CRASH-2), PPH (WOMAN trial)
✍️Consent for Transfusion
- Informed consent should be obtained and documented for all non-emergency transfusions
- Explain: indication, risks (infection, reaction, wrong blood), alternatives
- Patient has the right to refuse
- Document in notes and on transfusion prescription
Religious Considerations
- Jehovah's Witness: Many refuse all allogeneic blood and primary components. May accept cell salvage in a closed circuit. Always check individual preferences. Advance Directive/Refusal card must be respected in competent adults.
- Islamic ruling: Blood transfusion is generally considered permissible (halal) under the principle of necessity (darura). Most Islamic scholars and GCC medical authorities accept transfusion as treatment. Individual patient beliefs should still be explored.
Jehovah's Witness — Clinical Protocol:
- Always discuss privately (away from family)
- Assess capacity — must be competent adult decision
- Document specific refusals in writing
- Escalate to senior clinician and legal team if life-threatening
- Children: court order may be sought
- Maximise PBM strategies (TXA, cell salvage if acceptable)
🧪Pre-Transfusion Blood Sampling
Group & Screen (G&S)
- Determines ABO/Rh group and screens for unexpected antibodies
- Valid for 3 days (72h) in most labs if recently transfused/pregnant; may be longer in elective patients
- Required before crossmatch can be performed
Crossmatch
- Electronic crossmatch: Computer-confirmed ABO/Rh compatibility if negative antibody screen and two previous concordant samples. Faster (~5 min).
- Serological (full) crossmatch: Patient serum tested against donor RBCs. Required if antibody screen positive or policy dictates. Takes 45–60 min.
- Emergency release: O negative uncrossmatched while crossmatch performed
Correct Sample Labelling — CRITICAL
WBIT: Wrong Blood In Tube This is the most common serious transfusion hazard reported to SHOT (UK) and equivalent GCC systems. A mislabelled blood sample can lead to ABO-incompatible transfusion and patient death.
- Label the sample at the bedside immediately after collection
- Never pre-label tubes
- Required information: full name, date of birth, hospital number, date/time, collector's signature
- Most labs require two concordant samples (from two separate occasions or venepunctures) before issuing uncrossmatched blood electronically
✅Bedside Patient Identification Check
MANDATORY 2-Nurse Check: All blood components must be checked by two trained staff (at least one registered nurse) at the bedside immediately before transfusion commences.
Three Patient Identifiers (active check — ask, don't tell)
- Patient full name — ask patient to state their name; verify against wristband
- Date of birth — verify against wristband and prescription
- Hospital/MRN number — verify against wristband, prescription, and compatibility label
Blood Unit Checks
- Donation/unit number on blood bag matches compatibility label
- ABO and Rh group on bag matches patient's group on prescription/compatibility label
- Expiry date and time of blood unit
- Visual inspection: haemolysis (pink/red discolouration), clots, leaks, unusual colour, swirling absent in platelets
- Prescription confirmed: component, dose, rate, any special requirements (irradiated, CMV-neg)
💉IV Access & Equipment
IV Cannula Size
- Routine transfusion: 18G (pink) or 20G (pink/blue) — adequate flow
- Rapid transfusion/MTP: 16G (grey) or larger; consider central line or introducer
- Smaller gauges (22G) acceptable in elderly/difficult access but prolong transfusion time and may haemolyse RBCs at high pressure
Blood Giving Set
- Must use a blood administration set with 170–200 micron filter to remove microaggregates and cell debris
- Change giving set after each unit or per trust policy (usually every 12h or after 4 units of RBC)
- Do NOT add medications to blood or infuse concurrently via the same line
- Only 0.9% NaCl may be used with the same line (Hartmann's/dextrose can cause haemolysis or clotting)
Blood Warmers
Indications for blood warming:
- Massive transfusion (>50 mL/kg/h or >2 units RBC rapidly)
- Patients with cold agglutinin disease
- Neonatal transfusion
- Rapid transfusion via central line near heart
- Target warmed temperature: 37°C — never exceed 42°C (causes haemolysis)
- Use approved in-line blood warmers only — never improvise (microwave/hot water)
- Document use of blood warmer
⏱️Transfusion Rates & Observations
| Component | Standard Rate | Maximum Duration per Unit |
|---|---|---|
| Red Blood Cells | 1 unit over 2–4 hours | 4 hours (discard if exceeded) |
| Platelets | 1 adult dose over 20–30 minutes | 30–60 minutes |
| FFP | Typically over 30–60 minutes | 4 hours from thawing |
| Cryoprecipitate | Over 15–30 minutes | 4 hours |
| Albumin 4.5% | Clinician directed | As per manufacturer |
Vital Signs Observations
| Time Point | Parameters | Rationale |
|---|---|---|
| Pre-transfusion (baseline) | BP, HR, Temp, RR, SpO2 | Detect new changes early; document normal baseline |
| 15 minutes after start | BP, HR, Temp, RR, SpO2 | Most serious acute reactions occur in first 15 min |
| During transfusion | Nurse present/within visual range | Early detection of reactions |
| On completion | BP, HR, Temp, RR, SpO2 | Document outcome; detect delayed onset TACO/reaction |
| Post-transfusion 1h (some trusts) | BP, HR, Temp | Detect TACO in high-risk patients |
Clinical tip: The most important observation window is the first 15 minutes — the nurse must remain with the patient and observe for any adverse signs. If the patient is unable to report symptoms (sedated, confused), closer monitoring is required throughout.
🚨Massive Transfusion Protocol (MTP)
Activation Criteria (any one)
- Predicted or actual transfusion of >10 units RBC in 24 hours
- Blood loss >150 mL/min or active haemorrhage not responding to initial resuscitation
- Trauma with haemodynamic instability
- Major obstetric haemorrhage (PPH >1500 mL or escalating)
- Major surgical haemorrhage
Haemostatic Resuscitation Ratio
Target 1:1:1 ratio: RBC : FFP : Platelets (e.g., 6 units RBC : 4 units FFP : 1 adult dose platelets). Mimics whole blood and prevents dilutional coagulopathy.
MTP Management Steps
- Activate MTP via switchboard/lab — inform blood bank
- Large-bore IV access ×2, send FBC, coagulation, cross-match, fibrinogen, TEG/ROTEM if available
- Issue O negative uncrossmatched RBC immediately if needed
- TXA (Tranexamic acid): 1g IV over 10 min, then 1g over 8h — must be given within 3 hours of major haemorrhage onset (CRASH-2, WOMAN trials)
- Give cryoprecipitate early if fibrinogen <1.5 g/L
- Correct hypothermia, acidosis, hypocalcaemia ("lethal triad")
- IV calcium (10 mL 10% calcium chloride) after every 4 units RBC — citrate chelates calcium
- Goal-directed therapy using TEG/ROTEM when available
- Blood warmers mandatory for all rapid transfusion
- Document all blood products given meticulously
Lethal Triad in Major Haemorrhage: Hypothermia + Acidosis + Coagulopathy. Each worsens the others. Actively prevent and reverse all three simultaneously.
Transfusion Reaction Identifier Tool
Select all symptoms the patient is currently displaying, then click Analyse to identify the most likely reaction and receive management guidance.
⚡Acute Transfusion Reactions (within 24 hours)
| Reaction | Key Features | Severity | Immediate Action |
|---|---|---|---|
| FNHTR Febrile Non-Haemolytic |
Fever ≥1°C rise, chills. No haemolysis. | Mild | Slow transfusion, paracetamol, monitor. May continue if improved and haemolysis excluded. |
| Allergic (mild) | Urticaria, pruritus, localised rash — no systemic features | Mild | Slow/pause transfusion. Antihistamine (chlorphenamine). May restart if resolved. |
| Anaphylaxis | Urticaria + bronchospasm + hypotension + angioedema. Rapid onset. | EMERGENCY | STOP transfusion. Adrenaline 0.5 mg IM (1:1000). ABCDE. Antihistamine + hydrocortisone. 999/Code Blue. |
| Acute Haemolytic ABO Incompatibility |
Fever, rigors, loin/back pain, haemoglobinuria, shock, DIC, renal failure. Can occur after just 10 mL. | EMERGENCY | STOP transfusion immediately. IV fluids. Call doctor urgently. Recheck patient ID vs blood unit. ICU involvement. |
| TACO Circulatory Overload |
Dyspnoea, hypertension, peripheral oedema, raised JVP, bilateral crackles, new pulmonary oedema on CXR. During or within 6h of transfusion. | Moderate–Severe | Stop or significantly slow transfusion. Sit upright. Furosemide IV. O2. Call doctor. Monitor fluid balance. |
| TRALI Acute Lung Injury |
Acute hypoxia, non-cardiogenic pulmonary oedema, bilateral infiltrates on CXR within 6 hours. No prior evidence of ALI. Hypotension. | EMERGENCY | STOP transfusion. Supportive: O2, mechanical ventilation if needed. Do NOT give diuretics. ICU admission. Report to blood bank and SHOT/haemovigilance. |
| Bacterial Sepsis | High fever/rigors/hypotension shortly after (especially platelets). Rapid deterioration. | EMERGENCY | STOP transfusion. Blood cultures (patient + bag). Broad-spectrum antibiotics. Sepsis Six protocol. ICU. |
🕐Delayed Transfusion Reactions (>24 hours)
Delayed Haemolytic Transfusion Reaction (DHTR)
- Occurs 3–14 days post-transfusion
- Due to anamnestic (secondary) antibody response to allogeneic RBC antigens
- Features: unexplained fall in Hb, fever, jaundice, positive DAT
- Usually mild; rarely severe (especially in sickle cell patients)
Transfusion-Associated GvHD (TA-GvHD)
- Donor lymphocytes engraft and attack host tissues
- Features: fever, rash, diarrhoea, hepatitis, pancytopenia. Onset 1–6 weeks. Mortality >90%.
- Prevention: irradiation of cellular blood products in at-risk patients
Transfusion-Transmitted Infections (TTI)
- HIV, HBV, HCV: extremely rare with current NAT testing (<1 in millions)
- Hepatitis E: emerging risk; now screened in many countries including UK
- Malaria, Chagas, West Nile Virus: donor screening + travel deferral
- Prion diseases (vCJD): leucodepletion as risk reduction measure
Post-Transfusion Purpura (PTP)
- Thrombocytopaenia 5–12 days post-transfusion
- Anti-platelet antibodies (usually anti-HPA-1a)
- Treatment: IVIG (first line)
Iron Overload
- Affects chronically transfused patients (thalassaemia, sickle cell, MDS)
- Each unit RBC contains ~200 mg iron
- Iron chelation therapy required (deferoxamine, deferasirox)
📊Haemovigilance: SHOT System & GCC Reporting
SHOT (UK — Serious Hazards of Transfusion)
- UK national haemovigilance scheme — voluntary, anonymous reporting
- All serious adverse events and near-misses should be reported
- Most commonly reported errors: IBCT (Incorrect Blood Component Transfused), WBIT (Wrong Blood in Tube)
- Reports drive national policy changes and learning
GCC Haemovigilance
- Saudi Arabia: CBAHI (Central Board for Accreditation of Healthcare Institutions) mandates haemovigilance reporting
- UAE: DHA/DOH facility-level incident reporting systems
- Qatar: CIRE (Central Incident Reporting and Learning System)
- All GCC Joint Commission International (JCI)-accredited facilities have transfusion safety committees
- International ISBT (International Society of Blood Transfusion) defines terminology and adverse event definitions globally
Near-miss reporting is as important as adverse events. Near-misses reveal systemic risks before harm occurs. Nurses should always report near-misses without fear of blame — a just culture is essential.
🤰Massive Postpartum Haemorrhage (PPH)
Definition & Triggers
- Primary PPH: blood loss >500 mL vaginal delivery; >1000 mL caesarean section within 24h
- Major PPH: >1000 mL with ongoing bleeding or haemodynamic compromise
- Causes: Tone (uterine atony 80%), Tissue (retained products), Trauma, Thrombin (coagulopathy)
Medical Management
- Oxytocin 5 IU slow IV bolus → infusion 40 IU in 500 mL
- Ergometrine 250–500 mcg IM (avoid hypertension)
- Carboprost (prostaglandin F2α) — if uterus not responding
- Misoprostol 800–1000 mcg sublingual/rectal
- TXA 1g IV within 3 hours (WOMAN trial: reduces deaths from bleeding)
Transfusion in PPH
- Activate MTP early — do not wait for lab confirmation
- Target fibrinogen >2 g/L — give cryoprecipitate early
- 1:1:1 resuscitation ratio (RBC:FFP:platelets)
- Repeat fibrinogen every 30–60 min during massive haemorrhage
- Calcium replacement: 10 mL 10% CaCl2 IV every 4 units RBC
Cell Salvage in Obstetrics
- Acceptable in PPH — evidence does not support harm from amniotic fluid contamination with leucocyte depletion filter
- Use leuocyte depletion filter when using cell salvage in obstetric cases
- Offered as alternative to Jehovah's Witness patients (if acceptable to patient)
🚑Trauma Massive Haemorrhage
Haemostatic Resuscitation Principles
- Permissive hypotension: Target SBP 80–90 mmHg in penetrating trauma until surgical haemostasis achieved (avoid over-resuscitation diluting clotting factors)
- Exception: traumatic brain injury (TBI) — maintain SBP >90 mmHg to prevent secondary brain injury
- Damage control resuscitation: 1:1:1 ratio as early as possible
- TXA within 3 hours of injury (CRASH-2 trial) — do NOT give after 3h (increased mortality)
Assessment Tools
- ABC Score (Assessment of Blood Consumption): penetrating mechanism, HR>120, SBP<90, positive FAST — score ≥2 predicts need for MTP
- TEG/ROTEM: Viscoelastic haemostatic assay — guides specific component therapy, reduces empirical blood product use
- REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta): emerging technique for proximal haemorrhage control
Hypocalcaemia in massive transfusion: Citrate in blood products chelates calcium. Give calcium replacement empirically during MTP — hypocalcaemia impairs cardiac function and coagulation.
👶Neonatal & Paediatric Transfusion
Neonatal Transfusion — Special Requirements
- Irradiated RBCs and platelets (immature immune system — risk of TA-GvHD)
- CMV-negative or leucodepleted components
- Fresh blood preferred (stored <7 days) to reduce hyperkalaemia risk
- Small volume top-up transfusions: 10–20 mL/kg over 2–4h
- Glucose-containing solutions not used with blood
Exchange Transfusion
- Neonatal hyperbilirubinaemia: 2-volume exchange (160 mL/kg) replaces ~85% of RBCs
- Neonatal sickle cell crisis / haemolytic disease of the newborn (HDN)
- Performed via umbilical vein catheter in neonates
- Risks: air embolism, thrombosis, electrolyte imbalance, hypocalcaemia, infection
Intrauterine transfusion (IUT): For severe fetal anaemia (hydrops, severe HDN). RBCs transfused directly into umbilical vein under ultrasound guidance.
🌙Sickle Cell Disease (SCD) — GCC Relevance
GCC Epidemiology
- SCD and sickle cell trait highly prevalent in Saudi Arabia (Qatif/Eastern Province), Bahrain, UAE, Oman, Qatar
- HbSS prevalence ~0.5–1% in Eastern Saudi population
- National haemoglobinopathy screening programmes established across GCC
- Mandatory pre-marital screening in Saudi Arabia (since 2004) and other GCC states to reduce new cases
Transfusion in Sickle Cell
- Simple transfusion: Severe acute chest syndrome, aplastic crisis, sequestration crisis, Hb <5 g/dL with symptoms
- Exchange transfusion (erythrocytapheresis): Stroke prevention, acute stroke, multi-organ failure, refractory priapism. Target HbS <30%
- Chronic transfusion programme: Stroke prevention in children with abnormal TCD — target HbS <30%, Hb 9–10 g/dL
Alloimmunisation Risk
- SCD patients develop alloantibodies in 20–50% of cases — higher than general population
- Use phenotypically matched RBCs (Rh: C, D, E; Kell system minimum)
- Extended phenotype matching (Duffy, Kidd, MNS) reduces alloimmunisation
- Maintain a dedicated antibody history record
Iron Overload Management
- Serum ferritin target <1000 mcg/L in chronic transfusion programmes
- Chelation therapy: Deferasirox (oral, once daily — preferred), Deferoxamine (SC/IV infusion)
- MRI T2* for cardiac and liver iron quantification
DHTR in Sickle Cell: Delayed haemolytic transfusion reaction in SCD can be life-threatening — Hb drops below pre-transfusion level, severe crisis. Manage with steroids, IVIG, erythropoietin; avoid further transfusion if possible.
🔄Therapeutic Apheresis
Therapeutic Plasma Exchange (TPE)
- Removes patient's plasma (containing pathological factors) and replaces with FFP or albumin
- TTP (Thrombotic Thrombocytopaenic Purpura): First-line EMERGENCY treatment — removes ADAMTS13 inhibitory antibodies and replenishes ADAMTS13
- Myasthenia gravis, Guillain-Barré syndrome, ANCA vasculitis
- Large-volume paracentesis replacement in hepatic failure
Red Cell Exchange (Erythrocytapheresis)
- Automated removal of patient RBCs replaced with donor RBCs
- Acute stroke in SCD, HbSC, prevention of stroke in children
- Severe malaria with >10% parasitaemia and complications
- Advantage: reduces alloimmunisation and iron loading compared to simple transfusion
Cell Salvage — Contraindications
- Malignant cells in surgical field (relative — with radiotherapy)
- Active infection/sepsis in surgical field
- Use of certain substances (bone cement, hydrogen peroxide)
- Bowel contamination of surgical field
🧬Thalassaemia in GCC
- Beta-thalassaemia major highly prevalent in Gulf region — Iran, Iraq, Eastern Arabia historical gene pool overlap
- Regular transfusion programme: typically every 2–4 weeks to maintain pre-transfusion Hb >90–95 g/L
- Target post-transfusion Hb <150 g/L (to avoid hyperviscosity)
- Extended RBC phenotype matching mandatory to reduce alloimmunisation
- Iron chelation lifelong — deferasirox first line; deferoxamine SC infusion overnight via pump
- Cardiac T2* MRI annually for iron cardiomyopathy screening
- Allogeneic HSCT (haematopoietic stem cell transplant) is the only curative option — increasingly available across GCC
- Gene therapy trials ongoing — may offer future cure
🌍GCC Blood Transfusion Services
National Blood Services
- Saudi Arabia: Saudi Blood Transfusion Services (SBTS) — national programme under MoH. Blood safety standards aligned with WHO. Haemovigilance integrated with CBAHI accreditation.
- UAE: Dubai Blood Bank (Dubai Health Authority). Abu Dhabi Blood Bank (SEHA). Emirate-level services with national coordination.
- Qatar: Hamad Medical Corporation Blood Bank — one of the most advanced in the region. Pathogen inactivation technology in use.
- Bahrain: National Blood Bank of Bahrain — significant thalassaemia and SCD transfusion programmes.
- Kuwait/Oman: National blood transfusion centres under respective Ministries of Health.
Blood Donation in GCC
- All GCC countries pursue 100% voluntary, non-remunerated donation as WHO target
- Historically, family/replacement donation was common — now transitioning toward voluntary
- Challenge: cultural attitudes, low voluntary donation rates compared to Europe
- Expatriate workforce (large proportion of GCC population) provides a significant donor pool
- National blood campaigns (Ramadan donation drives, World Blood Donor Day)
- Saudi Arabia, Qatar, UAE have established national registries for haemopoietic stem cell donation
Islamic perspective on blood donation: The majority of Islamic scholars and GCC religious authorities classify blood donation as recommended (mustahabb) or at minimum permissible, based on the principle of saving life (hifz al-nafs). Both donation and receipt of blood are widely accepted.
📜GCC Licensing Exam Focus: DHA / DOH / SCFHS
High-Yield Transfusion Topics for GCC Exams
- ABO/Rh compatibility rules — especially universal donor/recipient
- Hb threshold for transfusion (70 g/L, 80 g/L in cardiac)
- Bedside identification checks — 3 identifiers, 2-nurse check
- WBIT — most common serious hazard
- FNHTR management — most common reaction; may continue
- Acute haemolytic reaction — STOP, IV fluids, call doctor
- TACO vs TRALI differential
- MTP 1:1:1 ratio and TXA within 3 hours
- Irradiated products — who needs them
- FFP: ABO compatible, thaw at 30–37°C, use within 4h
- Platelet storage: 20–24°C agitated, 5–7 days
- RBC storage: 1–6°C, 35–42 days
- Cryoprecipitate: fibrinogen/FVIII/vWF/FXIII — DIC, PPH
SCFHS Nursing Competency Areas
- Safe transfusion practice: pre-check, administration, monitoring
- Recognition and escalation of transfusion reactions
- Documentation of blood products (mandatory in Saudi healthcare)
- Patient Blood Management principles
- Special populations: SCD (Eastern Province), thalassaemia
- Ethical/legal: consent, refusal, Jehovah's Witness management
Common Exam Distractors
- Dextrose 5% can be used with blood (FALSE) — causes haemolysis
- FNHTR requires stopping transfusion permanently (FALSE) — may continue if improved
- Group O positive is universal RBC donor (PARTIALLY) — O negative is truly universal
- Blood can be kept at room temperature for 4h after starting (FALSE if not started) — 4h from removal from storage
🎯10 MCQ Practice Questions
1. A patient with blood group O Rh(D) negative requires an emergency RBC transfusion and their blood group is unknown. Which blood should be issued?
2. During the first 15 minutes of a red blood cell transfusion, the patient develops fever (38.5°C), chills, and back pain with falling blood pressure. What is the MOST likely diagnosis and FIRST action?
3. What is the correct storage temperature for packed red blood cells?
4. A patient develops acute hypoxia, bilateral pulmonary infiltrates on chest X-ray, and hypotension within 4 hours of a platelet transfusion. There is no evidence of fluid overload. What is the MOST likely diagnosis?
5. Which IV fluid is compatible with blood products and may be co-administered via the same giving set if needed?
6. What is the maximum duration for transfusing one unit of packed red blood cells once it has been removed from controlled storage?
7. A patient with sickle cell disease requires regular transfusions for stroke prevention. What is the target HbS percentage?
8. Tranexamic acid (TXA) must be administered within how many hours of the onset of major haemorrhage to be effective (based on CRASH-2/WOMAN trials)?
9. Which of the following patients MOST requires irradiated blood products?
10. What is the MOST common serious transfusion hazard reported in haemovigilance systems such as SHOT?