Table Of ContentThe
Clinical
Use
of
Blood
in
Medicine
Obstetrics
Paediatrics
Surgery & Anaesthesia
Trauma & Burns
World Health Organization
Blood Transfusion Safety
GENEVA
Contents
Preface
Acknowledgements
Introduction 1
PART 1: PRINCIPLES, PRODUCTS AND PROCEDURES
1 The appropriate use of blood and blood products 7
1.1 Appropriate and inappropriate transfusion 9
1.2 Blood safety 10
1.3 Prerequisites for the appropriate clinical use of blood 16
1.4 Principles of clinical transfusion practice 18
2 Blood, oxygen and the circulation 20
2.1 Body fluids and compartments 22
2.2 Blood 24
2.3 Oxygen supply to the body 28
3 Anaemia 38
3.1 Definitions 40
3.2 Measuring haemoglobin concentration and haematocrit 42
3.3 Clinically important anaemia 43
3.4 Interpreting haemoglobin values 44
3.5 Causes of anaemia 46
3.6 Adaptation to anaemia 47
3.7 Anaemia due to acute blood loss 48
3.8 Anaemia due to chronic blood loss 52
3.9 Chronic anaemia due to other causes 53
3.10 Principles of the treatment of anaemia 54
3.11 Principles of the prevention of anaemia 55
4 Replacement fluids 57
4.1 Definitions 59
4.2 Intravenous replacement therapy 60
4.3 Intravenous replacement fluids 60
4.4 Other routes of administration of fluids 64
4.5 Replacement fluids: characteristics 65
5 Blood products 72
5.1 Definitions 74
5.2 Whole blood 74
5.3 Blood components 75
5.4 Component separation by apheresis 81
5.5 Plasma derivative production (plasma fractionation) 81
5.6 Blood products: characteristics 82
6 Clinical transfusion procedures 94
6.1 Getting the right blood to the right patient at the
right time 96
6.2 Ordering blood products 100
6.3 Red cell compatibility testing (crossmatching) 108
6.4 Collecting blood products prior to transfusion 112
6.5 Storing blood products prior to transfusion 112
6.6 Administering blood products 115
6.7 Monitoring the transfused patient 122
6.8 Specialized procedures 124
7 Adverse effects of transfusion 126
7.1 Transfusion reactions 128
7.2 Initial management and investigation 129
7.3 Acute transfusion reactions 134
7.4 Delayed complications of transfusion:
transfusion-transmitted infections 140
7.5 Other delayed complications of transfusion 146
7.6 Massive or large volume blood transfusions 149
PART 2: TRANSFUSION IN CLINICAL PRACTICE
8 Clinical decisions on transfusion 155
8.1 Assessing the need for transfusion 156
8.2 Confirming the need for transfusion 156
9 General medicine 159
9.1 Anaemia 161
9.2 Deficiency of haematinics 172
9.3 Haemolytic anaemias 175
9.4 Malaria 177
9.5 HIV/AIDS 181
9.6 Glucose-6-phosphate dehydrogenase (G6PD)
deficiency 183
9.7 Bone marrow failure 184
9.8 Genetic disorders of haemoglobin 188
9.9 Bleeding disorders and transfusion 198
9.10 Congenital bleeding and clotting disorders 201
9.11 Acquired bleeding and clotting disorders 204
10 Obstetrics 209
10.1 Physiological & haematological changes during
pregnancy 211
10.2 Chronic anaemia in pregnancy 213
10.3 Major obstetric haemorrhage 219
10.4 Haemolytic disease of the newborn (HDN) 225
11 Paediatrics & neonatology 228
11.1 Paediatric anaemia 230
11.2 The management of paediatric anaemia 234
11.3 Paediatric transfusion in special clinical
situations 241
11.4 Bleeding and clotting disorders 243
11.5 Thrombocytopenia 244
11.6 Neonatal transfusion 245
12 Surgery & anaesthesia 255
12.1 Patient selection and preparation 257
12.2 Techniques to reduce operative blood loss 262
12.3 Fluid replacement and transfusion 264
12.4 Autologous blood transfusion 273
12.5 Care in the postoperative period 276
13 Trauma & acute surgery 279
13.1 Management of the acute surgical or
traumatized patient 281
13.2 Initial assessment and resuscitation 281
13.3 Reassessment 288
13.4 Definitive management 291
13.5 Other causes of hypovolaemia 291
13.6 The management of paediatric patients 292
14 Burns 296
14.1 The management of burns patients 298
14.2 Assessing the severity of burn 299
14.3 Fluid resuscitation in burns patients 302
14.4 Continuing care of burns patients 306
14.5 Burns prevention 308
PART 3: PUTTING IT INTO PRACTICE
15 Making it happen: what can I do? 311
15.1 Where do I start? 313
15.2 Developing a plan of action 317
15.3 Hospital transfusion committee 319
15.4 Guidelines on the clinical use of blood 320
15.5 Education and training on the clinical use of blood 323
Glossary 325
Index 331
Preface
Blood transfusion is an essential part of modern health care. Used correctly,
it can save life and improve health. However, the transmission of infectious
agents by blood and blood products has focused particular attention on the
potential risks of transfusion.
The World Health Organization (WHO) has developed the following integrated
strategy to promote global blood safety and minimize the risks associated
with transfusion.
1 The establishment of nationally coordinated blood transfusion
services with quality systems in all areas.
2 The collection of blood only from voluntary non-remunerated
donors from low-risk populations.
3 The screening of all donated blood for transfusion-transmissible
infections, including the human immunodeficiency virus (HIV),
hepatitis viruses, syphilis and other infectious agents, and
good laboratory practice in all aspects of blood grouping,
compatibility testing, component preparation and the storage
and transportation of blood and blood products.
4 A reduction in unnecessary transfusions through the
appropriate clinical use of blood and blood products, and the
use of simple alternatives to transfusion, wherever possible.
Many countries have established national blood transfusion services in
accordance with WHO recommendations and guidelines. However, few
countries have yet developed national policies and guidelines on the clinical
use of blood or provide systematic education and training on the clinical
use of blood and blood products.
In 1998, WHO published Recommendations on Developing a National
Policy and Guidelines on the Clinical Use of Blood. This document was
designed to assist Member States in developing and implementing national
policies and guidelines and ensuring active collaboration between the
blood transfusion service and clinicians throughout the management of
patients who may require transfusion.
The Recommendations emphasize the importance of education and training
in the clinical use of blood for all clinical and blood bank staff involved in
PREFACE
the transfusion process. The WHO team responsible for Blood Transfusion
Safety (WHO/BTS) has therefore developed The Clinical Use of Blood to
provide a set of comprehensive learning materials that can be used in
undergraduate and postgraduate programmes, in-service training and
continuing medical education programmes or for independent study by
individual clinicians. The pocket handbook that accompanies the module
is designed for quick reference by clinicians who need to make urgent
decisions on transfusion.
The Clinical Use of Blood is not designed to replace conventional textbooks
or to provide a definitive text on the clinical use of blood. Rather, its
purpose is to provide an accessible learning tool that will assist prescribers
of blood to make appropriate clinical decisions on transfusion and contribute
to wider efforts to minimize the unnecessary use of blood and blood
products.
The materials have been written by an international team of clinical and
blood transfusion medicine specialists and have been reviewed by a wide
range of specialists throughout the world. They have also been reviewed
by the WHO Department of Reproductive Health and Research, the
Department of Adolescent and Child Development, the Roll Back Malaria
Initiative and the Human Genetics Programme. Nevertheless, clinical
transfusion practice should always be based on national guidelines, where
available. Users are therefore encouraged to adapt the information and
guidance contained in the module and pocket handbook to conform with
national guidelines and established procedures in their own countries.
Dr Jean C. Emmanuel
Director, Blood Safety & Clinical Technology
World Health Organization
Acknowledgements
The World Health Organization acknowledges with thanks the many clinical and blood transfusion medicine
specialists who have contributed to the development of these learning materials.
Project Director Critical Readers
Dr Jean C. Emmanuel, Director, Blood Safety and Dr Imelda Bates, Consultant Haematologist, St
Clinical Technology, World Health Organization George’s Hospital Medical School, London, UK
Dr Sunil Bichile, Professor and Head, Department
Project Manager of Haematology, Topiwala National Medical College
Ms Jan Fordham, Director, Open Learning and BYL Nair Charitable Hospital, Bombay, India
Associates, London, UK
Dr John Davy, Plastic and Reconstructive Surgeon,
Harare, Zimbabwe
Clinical Editors
Dr Androulla Eleftheriou, Scientific Coordinator,
Dr Jean C. Emmanuel, Director, Blood Safety and
Thalassaemia International Federation
Clinical Technology, World Health Organization
Dr Elizabeth Letsky, Consultant Perinatal
Dr Brian McClelland, Regional Director, Edinburgh
Haematologist, Queen Charlotte’s and Chelsea
& South-East Scotland Blood Transfusion Service,
Hospital, London, UK
Edinburgh, UK
Dr S. Mitchell Lewis, Department of Haematology,
Dr Richard Page, Consultant Anaesthetist, Royal
Imperial College School of Medicine, Hammersmith
Cornwall Hospitals, UK
Hospital, London, UK
Authors Dr Guy Levy, Zentrallaboratorium, Bern, Switzerland
Dr Anthony Chisakuta, Consultant Anaesthetist,
Dr Laurie Marks, Consultant Anaesthetist, Harare,
Royal Belfast Hospital for Children, Belfast, UK
Zimbabwe
Dr Eve Lackritz, Assistant Chief for Science, Dr Stephen Munjanja, Obstetrician &
International Activities Branch, Division of HIV/AIDS Gynaecologist, Harare, Zimbabwe
Prevention, Centers for Disease Control and
Prevention, Atlanta, USA Professor Greg Powell, Department of Paediatrics
and Child Health, School of Medicine, University of
Dr Brian McClelland, Regional Director, Edinburgh Zimbabwe, Harare, Zimbabwe
& South-East Scotland Blood Transfusion Service,
Edinburgh, UK Dra Maria de los Angeles Rodriguez, Head of
Blood Bank, Hospital Naval, Viña del Mar, Chile
Dr Richard Page, Consultant Anaesthetist, Royal
Cornwall Hospitals, UK Mr Graham L. Sellars, Obstetrician &
Gynaecologist, Harare, Zimbabwe
Dr Henrik Zetterström, Medical Director,
Östersunds Hospital, Östersund, Sweden
ACKNOWLEDGEMENTS
Participants in WHO Informal Regional Participants in WHO Inter-Regional Evaluation,
Evaluation, Harare, Zimbabwe Limassol, Cyprus
11–12 April 1997 8–11 September 1997
Dr Henry W. Bukwirwa, Department of Dr Anwar Al-Khasawneh, Consultant General
Anaesthesia, Makerere Medical School, Mulago Surgeon and Head, Department of General Surgery,
Hospital, Kampala, Uganda Al Bashair Hospital, Amman, Jordan
Dr Meena Nathan Cherian, Professor, Department Dr Sunil Bichile, Professor and Head, Department
of Anaesthesia, Christian Medical College & of Haematology, Topiwala National Medical College
Hospital, Vellore, India and BYL Nair Charitable Hospital, Bombay, India
Dr M. E. Chitiyo, Medical Director, National Blood Dr Meena Nathan Cherian, Professor, Department
Transfusion Service, Harare, Zimbabwe of Anaesthesia, Christian Medical College &
Hospital, Vellore, India
Dr Alison M. Coutts, Chairman, Department of
Haematology, School of Medicine, University of Mrs Rosie Chimoyo, Nurse Anaesthetist, Malamulo
Zimbabwe, Harare, Zimbabwe Hospital, Makwasa, Malawi
Dr Vasumati M. Divekar, Professor of Dr Linda Ciu, Chief, Neonatal Clinic, University
Anaesthesiology, Patil Medical College, Bombay, Hospital Tirana, Tirana, Albania
India
Dr Michael B. Dobson, Consultant Anaesthetist,
Dr Michael B. Dobson, Consultant Anaesthetist, Nuffield Department of Anaesthetics, John Radcliffe
Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
Hospital, Oxford, UK
Dr Paul M. Fenton, Associate Professor,
Professor A. Latif, Department of Medicine, School Department of Anaesthesia, College of Medicine,
of Medicine, University of Zimbabwe, Harare, Blantyre, Malawi
Zimbabwe
Dr Valentina Hafner, Scientific Director, National
Dr Katherine Mauchaza, Paediatrician, Harare, Institute of Haematology & Blood Transfusion,
Zimbabwe Ministry of Health, Bucharest, Romania
Dr K. Nathoo, Department of Paediatrics, School of Dr Gabriel M. Kalakoutis, Head of Department of
Medicine, University of Zimbabwe, Harare, Obstetrics & Gynaecology, Makarios Hospital,
Zimbabwe Nicosia, Cyprus
Dr Dixon C. Tembo, Anaesthetist, Nkana Mine Dato’ Dr Mahmud bin Mohd. Nor, Head of
Hospital, Kitwe, Zambia Department of Surgery, Hospital Kuala Lumpur,
Kuala Lumpur, Malaysia
Dr Matt J. Oliver, Consultant Surgeon, Bulawayo,
Zimbabwe
Mr Christos Tapakoudes, Medical Laboratory
Superintendent, Blood Bank, Nicosia General
Hospital, Nicosia, Cyprus
Introduction
The Clinical Use of Blood forms part of a series of learning materials
developed by WHO/BTS in support of its global strategy for blood safety,
outlined in the Preface.
In 1994, WHO published Safe Blood and Blood Products, a set of interactive
learning materials designed for staff in blood transfusion services, public
health laboratories and hospital blood banks who are responsible for the
recruitment and selection of blood donors, and the collection, processing
and issue of blood for transfusion. The materials contain four modules:
Introductory Module: Guidelines and Principles for Safe Blood
Transfusion Practice
Module 1: Safe Blood Donation
Module 2: Screening for HIV and Other Infectious Agents
Module 3: Blood Group Serology
The modules are being used in many countries throughout the world, both
as resource materials in pre-service and in-service training programmes
and in distance learning programmes.
Establishing a Distance Learning Programme in Blood Safety: A guide for
programme coordinators was published by WHO/BTS in 1998 to provide
guidance for national blood programmes wishing to start a distance learning
programme in blood safety using these materials.
The Clinical Use of Blood
The Clinical Use of Blood complements the earlier learning materials
produced by WHO/BTS by focusing on the clinical aspects of blood
transfusion. It aims to show how blood and blood products can be used
appropriately at all levels of the health care system in any country, without
compromising standards of quality and safety.
It contains two components:
(cid:1) A module of learning material designed for use in education and
training programmes or for independent study by individual
clinicians and blood transfusion specialists
(cid:1) A pocket handbook for use in clinical practice.
1
