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An essential component of efficient management of the blood transfusion service and ensuring safety of blood supply is the availability of trained manpower as well as Education and training is fundamental to every aspect of blood safety. Having recognized the need to train all categories of staff in blood bank/ blood centre and blood storage centers NACO/NBTC identified training centers across the country, which have been imparting training on all aspects of Blood Safety since 2006. With rapid technological advances in transfusion medicine, continued training is vital for safe and quality blood This training module has been prepared with the objective of uniform standard of training for capacity building in the subject of transfusion medicine. This module includes all aspects of blood banking for Nurses working in the blood banks. The module is designed for the better understanding and comprehension of blood bank/ blood centre processes and procedures in order to improve technical and managerial skills of the trainees. Appropriate in-service training programmes will facilitate provision of trained manpower to help the blood bank/ blood centre staff to keep abreast with the latest developments, bring uniformity in operations. Schedules for training programmes and formats for important documents to be provided to the trainees are included in the Annexures. ACKNOWLEDGEMENTS NACO Representatives: Dr. Zarin S. Bharucha Dr. Debasish Gupta TRG members who contributed for the preparation of the training module: Dr. Neelam Marwaha Dr. R.K.Chaudhary Dr. Sunder Periyavan Dr. Jayashree Sharma Dr. K. Selvarajan Dr. Manisha Srivastava Experts who reviewed the Training Module: Dr. Sunil Rajadhyaksha Dr. Kabita Chatterjee Dr. Hari Krishan Dhawan Dr. Narinder Naidu Blood Donor Section 1.1 Donor recruitment and retention 1.2 Donor room procedures 1.3 Organisation of blood donation camp Immunohematology (IH) 2.1 Basic Red Cell Serology 2.2 ABO and Rh blood group typing 2.3 Compatibility testing Transfusion Transmitted Infections (TTI) testing Blood components Pretransfusion issues and Bedside practices Transfusion reactions Quality Management in Blood Transfusion Services Blood transfusion is an essential and life-saving support within the health care system but, there are concerns still regarding safety and availability of transfusion . These include • An insufficient number of voluntary non-remunerated blood donors to ensure an adequate supply of safe blood and blood products • Risk of the transmission of infections such as HIV, hepatitis B and C, and syphilis through unsafe transfusion • Unnecessary transfusions, which needlessly expose patients to the risk of acute or delayed reactions and transfusion-transmitted infection • Errors in the transfusion of blood and blood products. In order to ensure sustainability and overall safety of the entire transfusion process, an effective quality management system needs to be implemented. There are many definitions of quality, one of the simplest and most appropriate being "fit for purpose". In the context of blood transfusion, this means the setting and meeting of basic national quality standards and then continual quality improvement to ensure the safety of the transfusion process. This Training Program is designed for improving the Safety and Quality of blood transfusion by building capacity in all aspects of blood transfusion. The fundamental aim of the Training course is therefore to instill an understanding in the participants that for Blood safety a culture of quality has to be created in Blood Bank / Centre and that all staff needs to be fully aware of this culture and play their part in putting it into practice. An important part of the thrust of the Training course, and a measure of its effectiveness, is to ensure that course participants are aware of their central role in this process and to stimulate their interest and enthusiasm for quality. One of the fundamental objectives of the course is to help participants to develop a realistic plan of action for establishing an effective quality system in their own BTS. Blood safety depends on the following factors. • The incidence and prevalence of transfusion-transmissible infections in the blood donor population. • The effectiveness of the blood donor education and recruitment programme and procedures for donor selection and screening, including the deferral or exclusion of unsuitable donors. • The quality of screening of all donated blood for transfusion transmissible • The quality of blood grouping, compatibility testing, component preparation and the storage and transportation of blood products. • The extent to which blood and blood products are prescribed only when there is no alternative to transfusion for the particular patient. • The reliability of the system for ensuring that patients receive blood that is compatible with their blood group, red cell antibodies and other special It is important thereby that the quality and safety of all blood and blood products must be assured throughout the process from the selection of blood donors through to the administration of the product to the patient. 1. BLOOD DONOR SECTION Blood collection is the most essential function of a blood transfusion service and its organization should be given proper attention. Blood donation must be made a pleasant and rewarding experience for the blood donor. 1.1 DONOR RECRUITMENT AND RETENTION Recruitment and Retention of voluntary donors is the key to safeand sufficient blood supply. The goal to be achieved is a panel /registry of repeat donors who are well informed, committed and regularly screened for markers of transfusion transmitted diseases. The universal principle is careful planning, organization, knowing communities, what motivates people, effective communicationand campaign. Good service and support for donors as well as good public reputation goes a long way in increasing the voluntary safe blood donors. The other vital principle is that everyone involved in blood transfusion services should advocate for voluntary donation - doctors, technicians, nurses, donor recruiters as well as paramedics as all are part of a team with common purpose and an important message to get across. The task in bringing 100% voluntary donation will take some time but we have a greatest resource - PEOPLE. Success lies in Harnessing "PEOPLE POWER". 1.1.1 Donor Education • Awareness of the kind of information people need before deciding to donate blood is an important basis for Donor education, motivation and recruitment • Donor education about the need for safe blood is essential for donor recruitment • Community organisations and individual volunteers play an important role in donor recruitment • Educational material as leaflets, posters, films do support donor education to a • Educational talks delivered at important forums on safe blood help in motivating public to donate blood Effectiveness of donor education, motivation and recruitment should be monitored and evaluated on a regular basis. 1.1.2 Donor care and satisfaction The most important people are the blood donors themselves as without them the services cannot continue to operate • Everyone involved in interviewing and counselling should develop a friendly and tactful approach that encourages donors to be honest and accurate in their answers to questions about their medical history. • The health check should always be handled professionally so that the donors feel they are in good hands • The conditions surrounding blood donation area should be safe, pleasant and • It is essential that the staff should always be smart and clean in appearance with high standard of personal hygiene • They should have pleasant manners and be capable of conversing freely with donors at the time of donation. • An act of carelessness or lack of professionalism by staff during or after donation can be detrimental to the donors coming back again to donate blood. It is important to make the experience of blood donation pleasant for donors by providing Hygienic safe environment Short waiting time Privacy during pre donation counselling Adequate explanation of the procedure Reasons for temporary or permanent deferral Show interest in the individual donor Be sensitive to the donor's feelings of fear and embarrassment No indiscrete comment about donors previous health check/ donor deferral No chatting with other staff and ignoring the donor Thank donors WITH APPRECIATION so that they are motivated to come again 1.2 DONOR ROOM PROCEDURES Blood Donation Complex should be located at a place which is easily accessible for general public and patient's relatives. 1.2.2 Types of donors • Voluntary blood donors • Replacement/Relative donors • Professional donors • Autologous blood donors • Donor for special procedures (plateletpheresis / Plasmapheresis / erythrocytapheresis / hematopoietic stem cell collection) • Directed or designated donors 1.2.2.1 Voluntary non-remunerated donors The voluntary donors give blood voluntarily without receiving any payment in the form of money or a substitute for money. Their primary motivation is to help unknown recipients and not to obtain any personal benefit. They are the safest donors because they are more likely to be free from transfusion transmitted infections( TTIs ) as they have been educated about the importance of safe blood. Once they become repeat donors they are screened each time they donate blood thereby reducing the chances of window period donation. 1.2.2.2 Replacement donors The replacement donors come to the Blood Transfusion Services with a request from the patients treating physician giving particulars of the patients like Name, Ward, Diagnosis, and an estimate of the blood and blood components likely to be required. Members of the patient's family are under pressure to donate blood and may conceal potentially important information about their health status, particularly the risk of transmitting an infectious disease. Relatives who cannot find suitable or willing donors within the family may seek replacement donors who are prepared to give their blood for payment. Donors who are paid by the patient's family are less likely to reveal any reasons why they may be unsuitable as donors. 1.2.2.3 Professional donors They give blood in return for money. Though banned by regulations they still sometimes donate under the garb of replacement donors. They don't reveal their unsuitability to donate blood. Paid donors present a major risk to the safety of the blood supply for the following reasons. • Paid donors undermine the voluntary non remunerated system of blood donation which is the foundation of a safe blood supply. • The highest incidence and prevalence of transfusion-transmissible infections are generally found among commercial or paid donors. • They are often undernourished, in poor health and may donate their blood more frequently than is recommended. This may have harmful effects on their own health as well as presenting a risk to the recipients of their blood or providing little or no benefit. They should be rejected as per the following criteria of identification • Nervousness and aggressive behaviour • Vague answers • Needle marks on ante cubital areas of both arms • Socio economic status of donor not matching with the patient • Unwillingness to bring other donors 1.2.2.4 Autologous donors They are donors who donate blood for themselves, to be used at a later date. Recipients who serve as their own donors receive safest possible blood since the risks of TTI and alloimmunisation are eliminated. 1.2.2.5 Apheresis donors These are special donors who donate regularly the specific blood component required and need to be screened thoroughly before putting on the aphaeresis 1.2.3 Measurement of Hemoglobin 1.2.3.1 Hb Estimation by CuSO4 Test Principle: This is a qualitative test based on specific gravity: A drop of blood with hemoglobin concentration of more than 12.5 g/dl sinks in a CuSO4 solution of specific gravity 1.053. 30 ml copper sulphate working solution (Sp.gr.1.053) in a clean, dry test tube is used for determining haemoglobin. The working solution is changed after every 25 The fingertip is cleaned thoroughly with a spirit swab and allowed to dry. Medial side of the ring finger of the donor is pricked using a sterile lancet. The first drop of blood is wiped and next blood drop is allowed to fall into a beaker containing CuSO4 solution of specific gravity 1.053 from a height of at least 1 cm. If blood drop sinks to the bottom of the solution then Hb is more than 12.5 g/dl. If blood drop floats for more than 15 seconds then Hb is less than 12.5 g/dl. Donors with Hb more than 12.5 g/dl are accepted for donation In case if the haemoglobin is lower than 12.5 g/dL, prescribe haematinics and ask the donor to come for a re-check after one month. Preparation of CuSO4 for Hb Estimation To prepare 100 ml of copper sulphate working solution (Sp.gr.1.053) i. Carefully weigh 170gms of pure air dried crystals of CuSO4 and put in a conical flask and add distilled water to make it to 1000ml of stock solution ii. Cap the flask and mix well to ensure copper sulphate has dissolved iii. Sp gravity of the solution made is 1.100 iv. Add 51 ml of prepared stock solution to 49 ml of distilled water to make 100 ml of working solution. v. Check (Sp.gr of 1.053) by hydrometer. vi. Solution should be stored at room temp in tightly capped containers to prevent 1. Check the copper sulphate working solution against a light source for presence of precipitate and cloudiness. 2. Check the specific gravity of the solution using a hydrometer 3. Copper sulphate being a coloured solution the marking of a hydrometer corresponding to the upper meniscus of the solution should be 1.053 for 12.5g/dl 4. Arrange the blood samples according to Hb concentration in a rack 5. Obtain samples of known Hb values. 6. Transfer 30 ml of copper sulphate working solution in a tube. 7. Mix the sample of known Hb concentration by inversion 8. Allow one drop of blood to fall gently into the copper sulphate solution 9. Repeat the procedure for all blood samples 10. Record the results in the record book Hb concentration Blood drop floats Blood drop sinks Blood drop sinks slowly or stays midway Quality Control of CuSO4 Date of Preparation of working solution Technician _ Specific gravity < or > 12.5 hemoglobinometer CuSO4 (stock solution) Date of preparation Vol of stock solution prepared Weight of dry crystal of CuSO4 used --------------------------------------- Specific gravity 1.2.3.2 Hb. Estimation by portable digital Haemoglobinometer This is a quantitative test. Sodium deoxycholate haemolyses the erythrocytes and releases haemoglobin. Sodium nitrate converts haemoglobin to cyanmethhemoglobin which together with sodium azide gives azidemethhemoglobin. The absorbance is measured at two wavelengths 570 and 880mm in order to compensate for turbidity in the sample. Microcuvette can be stored for a period of 2 years from the date of manufacture but once opened it is stable only for three months. i. The middle finger tip is cleaned thoroughly with spirit swab and allowed to dry. ii. The middle finger is punctured firmly near the tip with sterile disposable lancet. A good free flow of blood is ensured, the finger is not to be squeezed repeatedly since it may dilute the drop of blood with excess tissue fluid and gives false low iii. The first drop of blood is wiped and then the drop of blood is allowed to fill the cuvette completely in one continuous process. iv. Wipe off excess of blood on the outside of cuvette. Make sure that no blood is withdrawn out of the cuvette in this procedure. v. Place in the filled cuvette in to the cuvette holder immediately and push it in to the measuring position. vi. Results are displayed with in 15-45 sec as gm/dl vi. Dispose the cuvettes and lancets in 1% sodium hypo chlorite solution in puncture proof container. 1. Donor is accepted for blood donation if haemoglobin is more than 12.5 g/dL. 2. However, if haemoglobin level is less than 12.5 g/dL donor is deferred. Prescribe Haematinics after investigating for anaemia and ask the donor to come for a recheck after one month. 1.2.4 Donor selection for whole blood donation Donors' selection is critical to the success of supply of safe blood and its products The purpose of donor selection is to identify any factors that might make an individual unsuitable as a donor, either temporarily or permanently. Donor selection is done by a qualified medical officer and is based on medical history, limited physical examination and simple laboratory tests. It should be done very carefully in order to avoid any untoward effect either to the donor or to the recipient. 1.2.4.1 Age: Age should be between 18-65 yrs. 1.2.4.2. Medical history Donors are asked regarding their present and past medical history for their acceptance or their deferral as blood donors. Permanent Deferral • Hepatitis B or C • Diabetics on insulin • Malignant disorders • Abnormal bleeding • Asthmatics on steroid • Heart diseases • Tuberculosis/Leprosy • Polycythemia Vera • Thalassaemia/Sickle cell • G6PD deficiency • AIDS related complex • High risk group* *History of any genital ulcers or sores, history of multiple sexual partners and history of Temporary Deferral • History of major surgical intervention within last 1 year • History of minor surgical intervention within last 6 months • History of typhoid in last 1 year • History of hepatitis in family / close contact within last 1 year • History of dental manipulation in last 3 days 1.2.4.3 Infectious diseases Ask the donor regarding the following to rule out any infectious diseases • History of contact with a person with jaundice; defer for 12 months • History of malaria duly treated within 3 months • History of tattooing or ear/nose piercing within 6 months • Recent history of any unexplained weight loss, fever or lymphnode enlargement • History of upper respiratory tract infections, diarrhea, gastroenteritis in last 2 1.2.4.4 Immunization and vaccination • Hepatitis B vaccination in last 1 week. • Persons immunized with toxoid or killed vaccine after 48 hours are acceptable as blood donors if they are symptom free and afebrile. • Following inoculation of a live attenuated vaccine, a donor is deferred for 2 • Donors who have had passive immunization using animal serum products should be deferred for 12 months after the last injection • Donors should be deferred at least for 1 year after vaccination for rabies. 1.2.4.5 Medication • Mild analgesics and oral contraceptives are not reasons for deferral. However donors on salicylates (i.e. aspirin related compounds) should not be allowed to donate blood for platelet rich plasma or platelet concentrate; if the above medicines are ingested within last 72 hours • Donors taking antibiotics should be deferred while on medication • Donors taking drugs of "unknown nature" should be deferred • Donors taking therapy for severe acne with retinoids should be deferred for 1 month after completion of therapy • Donors with history of human growth hormone replacement therapy are permanently deferred 1.2.4.6. Female donors • Donors should be deferred during menstruation period, in case of any discomfort • A donor with recent history of abortion should be deferred from donation for 6 • Donors are not accepted during the period of pregnancy and till one year after delivery and during lactation. • Caesarian section to be considered as major surgery • Multiparous women (with three or more pregnancies) should be deferred for plasma/platelets donation to minimize the risk of TRALI. 1.2.4.7 Donors with red cell abnormalities are deferred. • Donors with any defect of RBC metabolism (i.e. G6PD deficiency) or structural abnormality (sickle cell anemia or thalassemia major) are permanently deferred • Donors with previous history of any hematological malignancy are also deferred • Donors who are thalassemia traits may be accepted if their hemoglobin is within • Donors of polycythemia vera are deferred permanently 1.2.4.8 Physical examination • A prospective donor should be in good health • Weight-Donors weighing more than 45 kg (for 350ml) and more than 55 kg (for 450ml) are acceptable • Blood pressure should be within acceptable range for a particular age group with or without medication. Diastolic BP: 60 to 90; Systolic BP: 100 to 160. • Palpebral conjunctiva, tongue and nails are examined for pallor. • Hemoglobin should not be less than 12.5g/dl • Pulse of the donor should be observed for one minute and should between 60 to100. Any irregularity in the pulse or pulse deficit more than 10 should be a cause for deferral • Phlebotomy site is examined for any infective lesions and scar of needle pricks indicative of intravenous drug abuse or frequent blood donations. • Systemic examination regarding heart, lungs and abdomen should be within There should be no generalised lymphadenopathy or epitrochlear nodes 1.2.5 Donor registration It is the information card to be filled by the donor in order to trace the donor in case need The following information must be included 1. Date of donation 2. Name of the donor 3. Father's/husband's name 4. Age (date of birth) 7. Address and telephone no. of residence/place of work 8. Blood group, if known 9. Date of last donation 10. Previous donor reaction, if any 11. Inclusion in Emergency panel 12. Previous deferral from donation (and its reasons) 1.2.5.1 Donor consent Consent of the donor should be taken for phlebotomy and screening tests for various transfusion transmitted diseases. Consent should also be taken for revealing the results of screening tests. 1.2.5.2 Directed donation Donors are to be selected as above and directed donor is informed, that his/her donation may be used in general pool if not transfused to the designated recipient. Consent is taken for the same in the register provided. 1.2.5.3 Pre-deposit Autologous donation Donor selection criteria can be relaxed in case of autologous donors but donor will be accepted only after receiving a written request from the treating/concerned doctor that the donor can withstand the stress of donation. Blood Bank physician may still refuse to accept the donor if he/she doesn't find the donor fit for donation. Blood is not taken into general pool as relaxation may have been done in donation selection criteria, however the units undergo mandatory testing for infectious disease markers and any reactive unit is discarded after notifying the concerned Minimum hemoglobin level should be 11 g/dl or hematocrit ≥ 34%. There is no upper and lower age limit and no weight restrictions. 1.2.5.4 Plateletpheresis General screening procedure and the prerequisites are the same as for routine whole blood donation along with following special requirements. a. Donor should meet all the acceptable criteria. b. Age of the donor should be between 18 to 50 years. c. The weight of the donor should be more than 55-60kg. d. The results of the TTIs of the donor should be non-reactive for all the TTIs. e. The pre-procedure platelet count should be ≥ 150,000 / µL. f. Donor should not have taken aspirin or any other platelet inhibitor in last 72 g. The donor should not be fasting prior to the procedure, however should refrain oily/spicy food, also citrus fruits or juices. h. Donor should have a prominent and easily accessible central anticubital vein in at least one of the arm. Donor without a prominent and easily accessible central anti cubital vein in at least one of the arm is deferred at once without undergoing the selection procedure. i. Donor with a prominent and easily accessible central anti cubital vein in only one of the arm is selected for the single needle procedure while donor with a prominent and easily accessible central anti cubital vein in both of the arms may be accepted for double needle procedure. 1.2.5.5 Donation interval • The minimum time gap between two blood donations should be 12 weeks/3 • Whole blood donation must be deferred for at least 72 hours after plateletpheresis in case of re-infusion failure, donor should not donate whole blood for 12 weeks 1.2.5.6 Private Interview A detailed sexual history should be taken. Positive history should be recorded on confidential notebook. It is important to ask donors if they have been engaged in any risk behaviour. Allow sufficient time for discussion in the private cubicle. Try and identify result-seeking donors and refer them to VCTC (voluntary counselling and testing centre). Reassure the donor that strict confidentiality is maintained. Pre donation counselling- donor should be given information on blood donation process and the procedures to identify their suitability as donors they should be encouraged to self exclude or Self Defer Donor self exclusion The decision by a donor not to give blood because they have engaged in risk behaviour or because of the state of their own health The decision by the donor to wait until an unsuitable condition resolves. Privacy and confidentiality should be maintained during donor 1.2.5.7 Acceptance and Rejection of the donor • Depending on the criteria of donor selection the donors are accepted or • Take consent for intimation of his test results if found reactive for further confirmation at ICTC for HIV and referral to Gastroenterologist if reactive for • When donors are deferred either temporarily or permanently they should be explained the reasons for deferral and appropriate documentation be done. 1.2.6 Blood collection procedure 1.2.6.1 Materials required  Demethylated Spirit  Isopropyl alcohol  Cotton/Gauze swabs  Artery Forceps  Pilot Tubes: Plain and EDTA  Oxygen Cylinder with accessories  First Aid Tray  Electronic Tube Sealer  Blood collecting Bags  Discard Jar with 1% Sodium Hypochlorite  Puncture Proof container  Artery Forceps, Scissors  Adhesive Plaster  Blood Bag Mixer  Comfortable donor couch or chair 1.2.6.2 Selection of Bag There are variations in the volume of blood collected and in the type of anticoagulant-preservative solution used. Different types of blood bags in use: • Triple with additive solution e.g. SAGM / ADSOL • Quadruple with additive solution e.g. SAGM / ADSOL Top and Bottom Selection of the bag depends on various factors as listed below: Whole blood/PRBC+FFP Whole blood/PRBC+FFP PRBC: Packed cells FFP: Fresh Frozen Plasma PC: Platelet Concentrate  Before use check the expiry date of the bag and look for any puncture, or discoloration of the bag visually. If found so reject the bag and do not use.  Use single bag when; 1. Components are not to be separated from that unit. 2. When autologous blood is collected for patients e.g. elective surgery. 3. Therapeutic phlebotomy is being performed on a patient. 1.2.6.3 Collection of blood • Receive donor cordially as he/she should feel that staff is caring, concerned and • After a thorough screening, the donor is asked to lie down on the donor couch in a well lit and air-conditioned environment. • Identification of donor must be re-checked by asking him/her to tell name and tally it with card, blood bag and sample tubes (pilot tubes) and registration Preparation of phlebotomy site: • Select prominent vein (preferably central) in the ante-cubital area, apply sphygmomanometer cuff, and inflate till 40 to 60 mm Hg. Alternately tourniquet can be used. Lower margins of the tourniquet should be one and half inch above the ante-cubital area to avoid contamination. • The area should be disinfected with two disinfectants – Iodine based and methylated spirit or isopropyl alcohol are used to prepare the site for • Position donor's arm in naturally extended position and provide handgrip and request the donor to squeeze firmly. • Do not use betadine if donor is allergic to iodine. • Start disinfection of the skin of about an area of 5 cm of diameter from the centre outwards in the circular motion. • Allow this solution to dry for 30 seconds. • If the phlebotomy site is touched after cleaning, repeat the skin disinfection • Set the blood collection monitor for desired volume and place the bag on it. • Clamp the bleed line of the blood bag using plastic clamp to ensure that no air enters the tubing or the bag once the needle cover is removed. • Keep the bevel of the needle upward and a shaft at the angle of 15 degree with the arm, insert the needle in the vein 1 to 1.5 cm by a bold single sharp prick. • Monitor filling of blood bag and assure proper mixing with anticoagulant. • Sign the donor record card after checking the number on the bag, card and tubes and indicate the arm used for phlebotomy. • Interact with donor to prevent reaction. Allow collection to continue until desired quantity of blood is collected and NEVER leave the donor alone. • Discontinue collection if donor feels uncomfortable or collection time is more than 10 min. or donor develops hematoma at venipuncture site. Note: If the collection is not completed it should be considered as a donated unit and should be discarded after due testing as undercollected. • In case of venipuncture failure, second venipuncture may be performed if the donor gives consent to do so. NEVER use same arm or bag for a second • Seal tubing by tube sealer and cut it 8 to 10 inches away from venipuncture end and take samples in pilot tubes. • Before separating collected unit of whole blood from donor couch reinspect the blood bag for any defects and recheck donor registration no. on blood bag, processing tubes, donor records and donor slip that is to be issued in case of Relative Donor / Directed Donor / Autologous Donor. • Remove sphygmomanometer cuff/tourniquet. • Apply pressure at phlebotomy site so that swab may not fall. Affix adhesive tape after verifying that there is no ooze at the venipuncture site and stable clot has • Rest and refreshment is to be given to donor and observe the donor for at least 15-20 minutes post donation. If he/she feels well, then he/she may be allowed to Observe the donor for 8-10 minutes on the donor chair • To prevent adverse reactions like giddiness ask the donor not to get up from the chair for 5 minutes even if he feels perfectly all right. • Observe for another 10 minutes in the refreshment area whilst donor has refreshment a packet of biscuit and a tetrapack fruit drink. • Inspect the venepuncture site before the donor leaves the donor room. Apply an adhesive tape only after oozing stops. If there is persistent oozing at the site of venepuncture, apply pressure with a dry, sterile cotton swab. If there is haematoma apply Thrombophob ointment gently over the area after 5 minutes. Inform the donor about the expected change in skin colour. If the pain persists, ask him/her to apply ice. • Issue the donor replacement/voluntary donor card and ensure that the donor puts his/her signatures on the card. • Thank the donor and encourage becoming a repeat regular voluntary blood • Ask the donor to write his comments/suggestions register kept in the donor refreshment room. 1.2.7 Post donation care A thank you card may be given. Instruct the donors regarding the following:- • Take more fluids for next 24 hours • Do not smoke or drive for next half an hour • Do not drink alcohol for next 24 hours • Do not go for a flight for next 24 hours if the donor is pilot by profession • If bleeding occurs from phlebotomy site raise the arm and press the venipuncture site. • If feeling faint or dizzy lie down with legs slightly raised above the head level. If symptoms still persist consult nearest doctor, blood bank doctor or clinician. • Remove the adhesive band after 5-6 hours. • Do not apply any medication on venipuncture site on your own. • Avoid lifting heavy weight or strenuous exercise to prevent bruising or bleeding from venipuncture site. • No extra/special diet is needed. • Rest and refreshment should be given to all. The first time donor, obese donor or female donor should be given extra rest and may be escorted to refreshment • Thank the donor for their valuable contribution and ask them to repeat the same for this noble cause. 1.2.8 Donor reaction and its prevention Definition: Untoward feeling by blood donor before, during or after blood donation is known as a donor reaction. 1.2.8.1 Types of reaction • Mild Vasovagal Reaction • Moderate Vasovagal reaction • Severe Vasovagal reaction 1.2.8.2 Mild Vasovagal reaction Symptoms : Pallor, perspiration specially on palms, forehead which may be generalized, sighing or yawning, hyperventilation, feeling of warmth or air hunger, dizziness, light headedness, nausea with or without vomiting. • Discontinue donation • Seal venipuncture site • Place donor in head low position. • Applly wet towels to donor's forehead and ask donor to cough • Loosen any tight clothing and ensure that the donor has clear airway • Talk to the donor to assure that it is nothing serious and he/she will be perfectly alright. • Monitor pulse, BP and respiration. • The donor should NEVER be left alone. • Allow a sufficient period of rest before he leaves the room. 1.2.8.3 Moderate Vasovagal reaction Symptoms: There is progression of all the symptoms of mild reaction and additional symptoms of bradycardia, shallow respiration, hypotension (systolic as low as 60mm Hg), quiet anxiety may be present. There is prolonged recovery. Donor must be protected from injury if unconsciousness occurs. Treatment: In addition to treatment of mild reaction administration of 95% O2 and 5% CO2 may be helpful in case of fainting with hyperventilation. Remove donor if possible from general donor area to another room or use a screen to prevent sympathetic fainting. In case facility for monitored administration of 95% O2 and 5% CO2 is not available, rebreathing in to a polythene pack is 1.2.8.4 Severe Vasovagal reaction Symptoms: All symptoms of mild or moderate reaction. With any or all of the following: incontinence of urine or faeces (it's very rare), convulsions focal or Treatment: Must prevent injury to donor, padded tongue blade need to be placed between teeth if convulsions are prolonged. Do not give anything by mouth during reaction. If there is no improvement within 30 minutes, shift the donor to emergency medical ward and administer 300-500 ml normal saline with or without dextrose. After recovery post donation instruction must be given to the donor and some additional instructions depending upon severity of the reaction. Record of such reactions must be mentioned on donor card/donor register and should be explained to the donor. Call donor next morning or evening for follow up and for the reassurance. Observation is very essential. Keep donor under observation in rest room. If need be, assistance should be provided to accompany the donor to his place to avoid any injury or accident. 1.2.8.5 Materials required to attend to any emergency in the post donation period.  Analgesic Tablets,Calcium and Vitamin C Tablets  Atropine Sulphate  Pheniramine Maleate  Glucocorticosteroid  Metoclopromide  Prochlorperazine Maleate  Sodium Bicarbonate  Glucose Saline (Sodium chloride and Dextrose 500 ml)  Savlon, Tincture Benzoine  Adhesive Plaster  Anti Histaminic Cream  Heparin and Benzyl Nicotinate (Thrombophob) ointment.  Smelling Salt-Spirit of Ammonia  Tongue Depressor  Oxygen Cylinder 1.3 ORGANISATION OF BLOOD DONATION CAMPS Blood donation camp can be organized by: 1. a licensed designated Regional Blood Transfusion Centre; or 2. a licensed Government blood bank; or 3. the Indian Red Cross Society 4. Blood bank approved by SBTC i. "Designated Regional Blood Transfusion Centre" shall be a centre approved and designated by a Blood Transfusion Council constituted by a State Government to collect, process and distribute blood and its components to cater to the needs of the region and that centre has also been licensed and approved by the licensing Authority and Central Licensing Approving Authority for the purposes ii. The designated Regional Blood Transfusion Centre, Government blood bank and Indian Red Cross Society shall intimate within a period of seven days, the venue where blood camp was held and details of group wise units collected in the said camp to the Licensing Authority and Central License Approving Authority. Various educational institution, non-government and religious organizations within and outside the city mainly organize voluntary blood donation camps. The camps are fixed through correspondence with organizers and motivators well in advance. The organizers are communicated in writing regarding the blood donation dates and necessary arrangements to be made at their end. 1.3.1 Procedure for organizing a blood donation camp The organizers or motivators are requested to furnish the following information in the confirmation letter: a Exact venue of the camp b Number of donors (approx) c Time for the camp d Refreshment for donors i.e. whether it will be arranged by the organizers or department will reimburse for the same. Name of organization Complete address with Tel./Fax/Pager/Mobil 1.3.2 The required number of Beds according to the expected number of donors Above 300 donors Big Tables - As per number of donor beds (2 tent house tables will be required for one bed). Folding donor couches for mobile camps are also available. Armless Chairs/Sofa set for donors in the refreshment area. It should be a well-lighted and ventilated hall. This area is further divided according the instructions of the Doctor in charge into a) Waiting area for donors b) Donation area c) Post donation care area Light snacks and fluids depending upon geographical preferences. 1.3.3 Donation phase Indoor like environment is created at the site of the blood donation camps. Mobile Unit is fully equipped with material and appliances for collection and transportation of blood. These camps are held every month within the city and outstation. For emergency care to donors, emergency box with desired medicines is always available. Donor reaction, if any, is managed at the donation site itself. 1.3.4 Post donation phase Post-donation care and refreshment is the same as mentioned in donor room procedures. List of donors with name, serial donor registration number, and card indicating donor's blood group along with a letter thanking them for donation are sent to organizers. The collected blood units are stored in transport boxes during the period of transportation from the venue of camps back to the blood bank. 1.3.6 Apparatus and equipments required for the mobile blood collection unit • Blood bags – Single, double and triple • Rubber bands • Registration numbers • ACD solution for pilot tubes • Pipette to dispense ACD solution • Weighing machine • Copper sulphate solution • Medical kit with necessary drugs • Adhesive plaster • Rexine sheets • Test tubes and racks • Marking pencils • Spirit/ Isopropyl alcohol/ Povidone iodine/ Chlorhexidine • Containers/ boxes to carry articles • Empty containers to keep swabs • Blood bag weighing scales • Blood bag mixers • Containers for transporting blood (ice boxes) • Banner of blood bank conducting camp • Donor instruction signboards – • Information for donors: Pre- and post-donation • Thank you cards • Identity badges for working staff • Literature or pamphlets regarding voluntary blood donation • Mobile phone • Telephone number of a nearby hospital/medical facility for medical emergencies • Soap case, soap • Blowers, heaters, blankets • Container/s for drinking water • Containers & colour coded plastic bags for disposal. 1.3.7 Records concerning Blood Donation Camp 1. Registration cards 2. Statement of Expenditure 3. Report proforma of staff 4. Proforma to note down donor reaction 5. Register for remarks, suggestions to blood bank by organizers or donors 2. IMMUNOHEMATOLOGY 2.1 Basic Red Cell Serology Blood Group Antigens Proteins or carbohydrates that cover the red blood cells make up a person's blood group. These are called blood group antigens. ABO blood group system Karl Landsteiner first discovered the ABO blood group system in 1900. He was able to divide blood into 3 groups; A, B & O. In 1902 the fourth group (AB) was discovered by two of his pupils (De Castelle & Sturli) Blood Group Antigen Ο only H antigens In addition to these A or B antigens there is another substance on red blood cells called Rh antigens. Rh D antigen is the commonest and the most immunogenic antigen of the Rh system. People who have Rh D antigen on their red blood cells are Rh positive. People who do not have Rh antigens on their red cells are Rh negative. Ο A, H and Rh D antigens Ο B, H and Rh D antigens Ο H and Rh D antigens, no A or B antigens Ο A, H antigens, no Rh D antigens Ο B, H antigens, no Rh antigens Ο A, H antigens, no Rh D antigen Ο Only H antigen, no A, B or Rh D antigen Blood Group Antibodies In addition to red cell antigens present on red cells there are blood group antibodies presenting a person's plasma. These are Anti-A antibodies and Anti-B antibodies. Table 1 shows the type of antigens on red cells and type of antibodies in plasma in different ABO blood groups. Group A person has A antigens on their red cells and Anti-B antibodies in their plasma. Group B person has B antigens on their red cells and Anti-A antibodies in their plasma. Group O person has neither A antigens nor B antigens on their red cells but they have both Anti-A and Anti-B antibodies in their plasma. Group AB person has both A and B antigens on their red blood cells. They do not have either Anti-A or Anti-B antibodies in their plasma. Antigens and antibodies of the ABO Blood Group System Antigens on red blood cells Antibodies in plasma Anti- A and Anti- B ABO and Rh blood group percentage distribution in India Approximately 4.5% of India population is Rh negative. Genotype and Phenotype The genes on the chromosomes determine the antigen present on the red cell. Three genes can be inherited in the ABO system. They are A,B and O genes. Out of these three genes O gene is an amorphic gene. Each person has two genes that come from mother and father; the following combinations of genes or genotypes are possible. Possible genotypes: AA, AO, BB, BO, AB, OO Mother (group A) Father (group A) Possible combinations AA, AO, AA, AO Blood group/phenotypes A A A A Mother (group A) Father (group AB) Possible combinations AA, OB, AB, OA Blood groups/Phenotypes A B AB A There are number of other blood group systems, but out of all ABO and Rh systems have major clinical importance. Some of these other blood group systems are Kell, Kidd, Duffy, Another important blood group is Bombay blood group. Main features of this blood group is absence of A,B and H antigens on red cells and plasma of these persons have antibodies anti-A, anti-B and anti-H. The phenotype of this group is Oh. This can be observed in vitro by lack of reaction of Bombay type red cells with anti sera A, B AB and H, whereas a person with O group does not react with anti-A,-B,-AB but reacts very strongly with anti-H antiserum and this indicates clear differentiation between O and Oh individuals. Bombay (Oh)group individuals can be transfused only Oh blood. 2.2 ABO and Rh Grouping Standard tube technique is used for cell and serum grouping. Refer to SOP in your blood bank for the procedure. Agglutination pattern of different blood groups + Indicate the presence of either agglutination or hemolysis - Indicate the presence of neither agglutination nor hemolysis Serum grouping is not reliable to determine the ABO blood group on: • Newborn babies upto 4 months. Selection of ABO compatible donor red blood cells Red cell ABO group Rh D positive recipient can be transfused Rh D negative blood. Rh D negative recipient either males or post menopausal females can be transfused Rh D positive blood if there are no Rh antibodies detected in their plasma. Rh D negative females in the child bearing age should be transfused only Rh D negative blood. 2.3 Compatibility testing Compatibility testing includes the following. 1. ABO and Rh grouping of the patient and the donor 2. Checking the previous blood transfusion records of the patient 3. Screening of the patients serum for unexpected antibodies 4. Crossmatching Compatibility test is the most important procedure in a blood bank. The purpose of compatibility testing is to prevent any transfusion reactions by detecting clinically significant antibodies in the patient's serum, which would reduce survival of the donor cells. Transfusion reactions may occur if antibodies in the recipient's serum are not recognized or detected in the compatibility test. This could result in reduced survival or rapid destruction of transfused cells or even death of the recipient. It is therefore essential that the compatibility test provides conditions suitable for the optimum reactivity of all clinically significant antibodies. Specimens required Patient's blood sample should be collected and clearly labeled at the bedside • 3-5 cc of blood collected into a plain bottle for a routine crossmatch • 0.5- 1 cc of blood from babies < 4months old • 7cc of blood collected into a plain bottle and 2cc of blood into an EDTA bottle should be sent to the reference laboratory at NBTC in case of any problem faced in Blood grouping and antibody testing during pregnancy Maternal samples should be tested for ABO and Rh(D) groups and the presence of unexpected antibodies at the first visit and in subsequent visits. When an antibody screening test is positive, the antibody specificity and significance should be identified. Pre transfusion testing of babies who are < 4 months old Samples from both mother and infant should be obtained. Crossmatch needs to be carried out using maternal serum. Test done on maternal sample:- • ABO and Rh D group • Screen for unexpected antibodies Investigations on the infant's sample:- • ABO & Rh group (cell grouping only) • Direct antiglobulin test (DAT) • In the absence of maternal serum or when there is gross ABO incompatibility between mother and infant, use infant's serum for crossmatching. Exchange transfusion Exchange transfusion may be used to manage severe anemia at birth and to treat hyperbilirubinaemia caused by HDN. In hyperbilirubibnaemia exchange transfusion helps to • Remove Bilirubin • Remove antibodies • Replace the baby's red cells with compatible red cells Selection of blood for exchange transfusions • The blood selected for exchange transfusion should be group O or ABO compatible with maternal and babies blood group • It should be Rh negative or Rh compatible with both the mother and the baby • It should be Kell negative • Hct of the pack should be 50-60% • The blood pack should not be older than 5 days.  This reduces the risk of hyperkalaemia  Ensure good post transfusion survival of red cells • The blood should be CMV negative • The blood should not be from directed donations • It is better to screen these red cells for sickle cell disease and G6PD deficiency Selection of blood for exchange transfusion  Whole blood can be transfused only when mother and baby are of the same  When mother and baby are not ABO identical, select red cell concentrate according to the chart - Replace with AB FFP or compatible FFP according to the above chart  If either mother or baby is Rh D negative, use Rh D negative red cells for exchange transfusion 3. TRANSFUSION TRANSMITTED INFECTIONS 3.1 Introduction Screening of donated blood for TTIs represents one element of strategies for blood safety and availability. The first line of defense in providing a safe blood supply and minimizing the risk of transfusion-transmitted infection is to collect blood from well- selected, repeat voluntary non-remunerated blood donors from low-risk populations. The prevalence of TTIs in voluntary blood donors is generally much lower than among replacement donors. A lower prevalence of TTIs in the donor population also reduces the discard of donated blood and hence results in improved efficiency and use of 3.2 Transfusion-transmissible infections The microbial agents of importance to blood transfusion services are those that are transmissible by blood transfusion and can cause morbidity and mortality in recipients. In order to be transmissible by blood, the infectious agent or infection usually has the following characteristics: 3.3 Characteristics of transfusion transmitted pathogens. (Barbara J, 2004) 1. Cause mild or asymptomatic infections such that infected potential donor would present (and be accepted) for donation. 2. If symptomatic, would have a long incubation period eg. months (HBV, HCV) or even years (HIV) prior to development of symptoms. 3. Might cause a "carrier state" of infection (HIV, HBV, HCV) 4. Might cause a "latent state" of infection in host cells by incorporating their own DNA in the host's DNA (HIV, HTLV, CMV) 5. Would be stable under the storage conditions at which blood and components 6. Would be present in blood components either in plasma or as a DNA copy in white cells (HIV) Following table shows various organisms that can be transmitted by blood transfusion 3.4 Various organism that can be transmitted by blood Hepatitis B virus (HBV) Hepatitis C virus (HCV) Hepatitis D virus (HDV) Trypansoma cruzi Human Immunodeficinecy Virus (HIV) Cytomegalovirus (CMV) Toxoplasma gondi Epstein Barr Virus (EBV) Some infections such as HIV, hepatitis B and hepatitis C remain present in the blood; this is often called a ‘chronic carrier state'. The blood of individuals who are chronic carriers will transmit the infection to others. New infections are called Incident' infections. The term incidence describes the frequency of new infections in a defined population within a defined period of time. The incidence tells us what is happening now. The term Prevalence describes the proportion of a population who, at a given time, has evidence of the infection. The prevalence of an infectious agent, such as HIV antibody, can tell us what has already happened. The term Window period describes the period when there is viraemia but no detectable evidence of antibodies. Blood taken in this period is usually infectious, but the virus cannot be detected by current screening tests as ELISA for detection of antibody to HIV Quality assurance and good laboratory practice are therefore essential in all areas of blood screening. It is mandatory that every unit of donated blood should be screened for transfusion transmissible infections using the most appropriate and effective tests, in accordance with National Blood Policy and DCGI guidelineThe Mandatory test for screening 1. Anti-HIV 1 & 2 antibodies 2. Anti-HCV antibodies 3. Hepatitis B Surface Antigen (HBsAg) 4. Treponema palladium HIV is transmitted through sexual contact, sharing of HIV contaminated needles and/or syringes, transfusion of blood/ components, and nosocomial exposure to HIV contaminated blood or bodily fluids. It can also be passed vertically from a mother to her infant. Using the present anti-HIV ELISA tests, antibody to HIVis detected approximately 21 days after exposure to infection. Newer technologies such as HIV-1 p24 antigen test and HIV nucleic acid amplification testing (HIV NAT) can significantly reduce the window period, from 42 days by HIV antibody assay to 16 days by HIV-1 p24 antigen test and 13 days by HIV Screening for HIV antibodies The test selected for donated blood should be a combined HIV-1/HIV-2 assay, which is highly sensitive and specific. All serum/plasma should be tested with one ELISA or simple/rapid assay. Units of blood yielding reactive or indeterminate test results must be considered as probably infected with HIV and should be discarded using universal safety instructions. The non-reactive units may be taken on blood inventory for use. Caused by hepatitis B virus (HBV), it is transmitted cutaneously through injection drug use, through exposure to contaminated blood or bodily fluids, sexually through heterosexual or male homosexual activities, vertically from mother to infant, and horizontally among household contacts The hepatitis B carrier state is highly prevalent affecting more than 10% of the potential blood donor population. Transmission by blood may be followed by acute hepatitis, followed either by resolution or by chronic hepatitis. The long term consequences are cirrhosis and primary liver cancer. Screening for Hepatitis B To reduce the occurrence of post-transfusion hepatitis, it is essential to screen all blood donations for hepatitis B surface antigen by the most sensitive and specific assays. Core antigen HBc helps to detect mutants missed by Hepatitis B surface antigen testing but is Units of blood yielding ELISA reactive or indeterminate test results must be considered as probably infected with HBV and should be discarded using universal safety instructions. The non-reactive units may be taken on blood inventory for use. HCV can also be transmitted through blood transfusion and hepatitis C has been recognized as an increasingly important infectious disease which is usually asymptomatic. About half the affected recipients develop chronic hepatitis and a substantial proportion eventually develops severe liver damage. Screening for Hepatitis C To reduce the occurrence of post-transfusion hepatitis, it is essential to screen all blood donations for hepatitis C antibody by the most sensitive and specific ELISA assays. Units of blood yielding ELISA reactive or indeterminate test results must be considered as probably infected with HCV and should be discarded using universal safety instructions. The non- reactive units may be taken on blood inventory for use. Syphilis is transmitted primarily through sexual contact with an infected individual who is in the primary, secondary or early latent stage of the disease. T. pallidum can also be transmitted from mother to fetus and from an infected donor to a recipient through unscreened blood or direct blood transfusion Screening for Syphilis : Serum samples from all blood units must be subjected to either the VDRL (Venereal Disease Research Laboratory) test or a treponemal test, such as Treponema Pallidum Haemagglutination (TPHA) test /RPR antigen test before transfusion. Any unit found positive should be discarded as per standard safety procedures Malaria: Presently, sensitive screening tests for malaria are not available. The most effective way of screening donors is to take proper history of malaria or of fever that could be due to malaria. Donor selection criteria are designed to exclude potentially infectious individuals from donating red cells for transfusion. No blood or blood product is released for transfusion until all required Mandatory tests are reported to be non reactive. 3.5 Preventive strategies for transfusion transmitted infections. A variety of strategies have evolved in recent years in an attempt to decrease the morbidity and mortality associated with TTI. These strategies are summarized in the following Box. I.] Careful donor selection. A] Repeat voluntary blood donors B] Education, counseling and retention such of donors C] Improvement in the blood donor eligibility criteria II.] Reduce the risk of product contamination A] Improved venepuncture site disinfection B] Removal of first aliquot of the donor blood III.] Improved blood component processing and storage. A] Optimizing storage temperature B] Universal leukocyte reduction IV] Improved pre transfusion blood testing A] Sensitive and specific serological testing B] NAT test on mini pools C] Visual inspection of component before use V] Reducing recipient exposure to blood donor A] Optimizing transfusion indications B] Increased use of single donor products Biosafety is the use of laboratory practices, procedures and equipments for safety when working with potentially infectious microorganisms. 4.2 Risk to healthcare workers (HCW) Blood is the most important source of HIV, HBV and HCV infections. The risk depends upon the following factors. • Prevalence of infected individuals in the population. • Type of exposure, e.g. exposure of intact skin, breached skin, mucous membrane or needle stick injury. • Quantity of blood to which HCWs are exposed e.g. more in case of hollow • The relative infectivity and concentration of the virus; with HIV the risk is 0.05 to 0.3% (viral load 10 to 100 viral particles per ml plasma) with HCV the risk is 3.0 to 10% (viral load is 10000 to 100000 viral particles per ml) with HBV the risk is 30% (viral load is 10000000 viral particles per ml). • Number of exposures. 4.3 Modes of exposure to blood borne pathogen in the laboratory are depicted in the table Modes of exposure to blood borne pathogens in the laboratory Source/modes of transmission Collection of blood/body Laboratory technician • Needle stick injury • Broken specimen container • Blood contamination of hand with skin Transfer of Specimen Laboratory Technician • Contaminated and transport worker container/requisition • Broken container • Spill/splash of specimen Processing of Specimen Laboratory personnel • Puncture of skin • Contamination of skin/mucous from contaminated work surface • Spills/splashes of specimen • Broken specimen container • Faulty techniques • Perforated gloves Cleaning/washing Laboratory support staff • Puncture of skin • Contamination of skin from contaminated glassware • Spills/splashes • Contaminated work surface Disposal of waste Laboratory support staff Contact with infectious waste specially sharps, broken containers Specimen transport/ Transport, postal staff Broken/leaking container or packaging. 4.4 Essential steps of biosafety. 4.4.1 Good Laboratory practices As a general rule all samples should be treated as though they are potentially infectious. 4.4.2 General Lab. Hygiene The work surfaces should be cleaned with a disinfectant when procedures are completed at the end of each working day. 1% sodium hypochlorite is a universal effective disinfectant. The staff should avoid eating and drinking in the labs. There should be restricted access to the labs and only authorized staff should be present. Mouth pipetting is to be totally 4.4.3 Universal (standard) precautions should be used consistently by all HCWs. These include barrier protection / personal protective equipment like gloves, lab coats, occlusive bandages on skin abrasions or cuts, plastic aprons for staff cleaning reusable items and disposing waste. Gloves should be of good quality, well-fitting and disposable. One should avoid touching exposed body parts like face with gloved hands. If gloves get torn while work, they should be removed immediately and hands washed with soap and running water. The protective lab coats and aprons should be removed while leaving the laboratory. 4.4.4 Safe handling of specimens and sharps All samples should be collected in screw capped containers and capped securely to prevent spills and leaks. Disposable syringes and needles should be used for sample collection. Used needles and syringes should be placed in puncture-proof containers. Used needles should not be recapped. Samples (pilot tubes) from donors should be placed in racks in upright position and transported to labs in leak-proof plastic or rigid thermocol containers. 4.4.5 Management of blood spills. Blood spills should immediately be covered with absorbent paper sheets or gauze sponges to contain the spread of blood, gloves must be worn while handling blood spills. Then it should be covered with 1% sodium hypochlorite for at least 30 minutes. The paper towels / gauze should be then disposed as biohazard waste. Any broken glass pieces should be swept with dustpan and brush and disposed as sharps. The spill should be reported immediately. The exposed site should be washed immediately. 4.4.6 Hepatitis B vaccination for all laboratory staff. 4.4.7 Post exposure prophylaxis (PEP) An exposure that may place a HCW at risk of contracting blood-borne infection is defined as a percutaneous injury, mucous membrane contact, prolonged contact with intact skin or immediate contact with breached skin. The exposure must immediately be reported to the appropriate authority and treated as an emergency. The exposed site should be washed immediately. Blood should be collected for testing after written informed consent. 4.4.8 PEP for HBV Recommendations for Hepatitis B prophylaxis following percutaneous or permucosal Treatment when source is found to be HBsAg – positive HBsAg - negative Source not tested HBIG x 1* and initiate Initiate HB vaccine Initiate HB vaccine Test for anti-HBs vaccinated known 1. If adequate, no 2. If inadequate, HB vaccine booster dose If known high-risk vaccinated known plus 1 dose of HB source, may treat as Test for anti-HBs Test for anti-HBs 1. If inadequate HBIG 1. If [email protected], x 1 plus HB vaccine HB vaccine booster 2. If adequate, no 2. If adequate, no *HBIG dose 0.06 ml/kg IM @ Adequate anti-HBsAg is > 10 SRU by RIA or positive by EIA. 4.4.9 PEP for HCV There is no vaccination and no recommended chemoprophyloxis. Only follow-up testing for sero-conversion is recommended. 4.4.10 PEP for HIV HIV Post-exposure prophylaxis evaluation Status of source (see below) Consider 2-drug 2-drug PEP /non-intact skin; small volume (drops) /non-intact skin; large volume (major blood exposure: not severe exposure: severe large bore hollow needle, deep injury, visible blood in device, needle in patient artery/vein Low risk HIV exposure is said to occur when the exposure source is asymptomatic and has normal CD4 counts. High risk HIV exposure is said to occur when the source has advanced AIDS, high viral load or low CD4 counts. Post-exposure chemoprophylaxis Zidovudine (AZT/ZDV) – 300mg twice/day is used for all types (4 weeks therapy) Lamivudine (3TC) – 150 mg twice a day is added to increase the effectiveness of ZDV and to prevent resistance to ZDV Expanded Regimen: Basic Regimen (AZT/ZDV + 3TC) 3 drugs (2 NRTIs + PI) (4 weeks therapy) Nelfinavir 750 mg three times daily or any other boosted protease inhibitor. (for higher risk categories – consult In case the HIV source person is on antiretroviral therapy, the ART physician must be consulted to know if there is any drug resistance. Follow-up in case of PEP As mentioned, the first blood sample is collected immediately after exposure. Subsequent blood samples are collected at 6 weeks, 12 weeks and 6 months to assess the seroconversion if any. During this period all standard precautions to avoid HIV dissemination should be observed. 4.5 Biomedical Waste Management 4.5.1 Biomedical waste means any waste, which is generated during diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals and including categories mentioned in Schedule I of the Biomedical Waste (Management & Handling) Rules, 1998, as published by the Ministry of Environment & Forests. 4.5.2 Categories of Bio-Medical Waste Treatment & disposal Human anatomical waste Incineration/deep burial Animal anatomical waste Incineration/deep burial Microbiology & Biotechnology Local autoclaving / microwaving/ Disinfection (/autoclaving/microwaving and mutilation/shredding) Discarded Medicines and Cytotoxic Incineration/destruction and drugs disposal in secured landfills Solid waste (items contaminated Incineration/autoclaving / microwaving with blood and body fluids) Solid waste Tubings, catheters, Disinfection by chemical Treatment intravenous sets etc.) autoclaving /microwaving and mutilation/shredding Disinfection by chemical treatment and discharge into drains Incineration Ash Disposal in municipal landfill Chemical treatment and discharge into drains for liquids and secured landfill 4.5.3 Colour coding and type of Container for Disposal of Bio-Medical Wastes Type of container Treatment options as Cat 1, Cat 2, Cat 3, Incineration / deep burial Autoclaving / microwaving / container/ plastic bag chemical treatment Plastic bag/ puncture Autoclaving / microwaving / proof container chemical treatment and destruction shredding Disposal in secured landfill 4.6 Disinfection 4.6.1 Disinfection is the reduction in the number of pathogenic microbes so that the material/object/surface becomes safe for handling. Sodium hypochlorite is the most frequently used general lab disinfectant. Its advantages are that it is affordable, easily available and has virucidal and bactericidal action. Its limitations are that the solution gradually loses its strength, hence requires daily preparation of fresh 1% solution from stock solution (generally available as 4%) and secondly it corrodes metals. Sodium hypochlorite should be poured in plastic jars or bins for use in labs. 4.6.2 Disinfection of glassware and plasticware is achieved by immersing in 1% sodium hypochlorite for at least 30 minutes. 4.7.1 In this process saturated steam under pressure is used to decontaminate the infectious material. The main factors influencing quality of steam disinfection are temperature, time and presence of saturated steam. A pressure of 15 psi at 121oC for 45 to 60 minutes is required for adequate microbial destruction. The quality of this procedure is checked with strips or vials of B. Stearo thermophilus, at least once a month. Records of autoclaved blood units and quality control must be maintained. 4.8 Biosafety practices should be in accordance with the Biomedical Waste Management and Handling Rules, the amendment of which is under consideration at the time of printing









5. BLOOD COMPONENTS 5.1 Constituents of Blood Blood is composed of plasma in which the following highly specialized cells are suspended • Red blood cells (erythrocytes) • White blood cells (leucocytes) Plasma contains proteins, chemical substances, coagulation factors and numerous metabolic substances. It is capable of clotting. Total blood volume The volume occupied by both cells and plasma in the vascular system is called the total In an adult, this is approximately 7% of body weight or 70 ml/kg. For example, a 60 kg man would have a blood volume of 70 x 60, which is 4200 ml. As children have higher water content, the blood volume is calculated to be 8% of body weight or 80 ml/kg. It is higher still in the neonate and is calculated to be 85–90 ml/kg Blood volume in different age groups Neonates 85–90 ml/kg Children 80 ml/kg Red blood cells (erythrocytes) are produced in the bone marrow under the controlling influence of the renal hormone erythropoietin. After entering the bloodstream, they have a life-span of approximately 120 days before being broken down in the reticulo endothelial system. The red cells contain the iron-containing pigment hemoglobin, whose primary function is to store and transport oxygen. Red cells are the most numerous of the cells in blood and normally occupy about 45% of the total blood volume. Hemoglobin is usually measured in grams per decilitre (g/dl) or grams per millilitre (g/100 ml) of blood. In adult males, a typical level would be approximately 14 g/dl and in adult females 13 g/dI. White blood cells White blood cells (leucocytes) are a family of cells consisting of: • Granulocytes They are produced in the bone marrow and lymphatic tissue. Their principal role in the blood is to identify, destroy and remove any foreign material that has entered the body. These cells are therefore important in fighting infection and in developing resistance to infection in response to natural exposure or immunization. White cells occupy less than 1% of the total blood volume. Platelets are small fragments of cells (megakaryocytes), which are produced in the bone marrow and contain enzymes and other biologically active substances. Their function is to respond to any vascular wall damage by gathering together at the site of injury to form an initial temporary platelet plug and releasing their contents into the blood. The released contents of platelets are largely responsible for the subsequent coagulation process by activating the blood clotting mechanism that results in the permanent deposition of a fibrin clot at the site of damage, preventing further bleeding. Blood component preparation is an essential part of the blood transfusion services. Blood needs can only be met by separating it into various components. Thus component separation and administration helps in rationalizing use of blood. Blood components are prepared using physical properties of blood for e.g., centrifugation, whereas blood derivatives are prepared by a chemical method, e.g. ethanol, in varying concentration and temperature for their separation. Primary goal of component therapy is to provide right component to the right patient in right quantity at the right time in right quality. 5.2 Component separation There are various methods to separate these components and the yield and quality of component depends upon the method applied. Various methods used are: - Gravity separation (b) Low and high speed refrigerated centrifugation Apheresis by cell separator The different components that can be separated from whole blood are as below: • Packed Red Cells • Leucoreduced Red Cells • Platelet Concentrate • Platelet rich plasma • Fresh Frozen Plasma • Cryopoor Plasma FVIII deficient plasma • Cryoprecipitate 5.3 Steps for Component preparation The basic procedures involved in components preparation are relatively simple and normally performed using closed, multiple blood bag systems. A. Special Precautions should be taken for blood collection for component preparation 1. Clean thoroughly to minimise bacterial contamination 2. Venipuncture should be smooth with good Blood flow 3. Duration of venesection should not be more than 8min 4. Adequate mMixing of bBlood and aAnticoagulant should be monitored 5. Appropriate vVolume of blood should be collected 6. Immediately sStrip and segment tubing 7. Appropriate storage is essential before processing B. Apparatus and equipment for blood component preparation Airconditioned work place Refrigerated centrifuge Laminar air flow Plasma expressor Clipper and clips / dielectric sealer Double pan weighing balance Dry rubber balancing material Artery forceps and scissors Refrigerator with temperature range 2 - 60 C 10. Deep freezers, minus 30 to 40 0C, minus 20 to 80 0C 11. Refrigerated water bath Insulated container for blood transportation A standardised validated protocol is to be followed for preparation of blood 5.4 Storage and shelf life of components For calculating the expiry date the Day of collection should be considered as Day ‘0'. The Date of expiry on the manufacturer's label on the blood bag should be the date by which blood should be collected from the donor. The date of expiry of blood or component unit is calculated from the date of collection of blood. Storage temperature Red cells with additive Platelet concentrate 5.5 Storage of Blood & Blood components prior to transfusion The ‘Blood cold Chain' is the system for storage & transportation of blood & blood components so that they are kept at the correct temperature at all times from collection from donor to administration to the patient. Any break in the blood cold chain increase the dangers for the recipients of blood components. Clinical staff is responsible for ensuring that blood products issued by the BTS for transfusion are kept at the correct temperature until their infusion into the patient. Red Cells & Whole blood Red cells & whole blood must always be stored at a temperature between +2 degree C to +6 degree C. They must never be allowed to freeze. The upper limit of 6 degree C is essential to minimize the growth of any bacterial contamination in the unit of blood. Below 2 degree C Red cells become haemolysed. Haemolysed cells if transfused cause renal failure & fatal bleeding problems. Whole blood & red cells should be issued from the blood bank in the blood transport box or insulator carrier that will keep the temperature under 10 Group specific red cells are issued after proper cross matching. Once issued red blood cells should be transfused within ½ hour of release from BTS. If not required should be sent back to BTS immediately. Fresh Frozen Plasma (FFP) Fresh Frozen Plasma is stored in BTS at -40 degree C or colder until it is thawed before transfusion. Most of the clotting factors are stable at refrigerator temperature except for factor V & VIII. Its approximate volume is 150-175 ml/bag. It is thawed at 30 degree C - 37degree C water bath. It takes about 30-45 minutes to thaw the FFP. It is transported in a blood transport box in which the temperature is maintained between +2 degree C to 6 degree C. Once thawed it should be infused within 30 minutes. If not required for immediate use it can be kept at 2 degree C – 6 degree C & transfused within 24 hours. Once thawed the FFP can not be refrozen & has to be discarded. So as not to waste blood components, demand only when essential & in the required quantities. Group specific FFP has to be transfused after proper cross matching. However, AB group plasma being a neutral plasma (no antibodies) can be transfused to any group patient. Platelets – Platelet Rich Plasma (PRP)/ Platelet Concentrate (PC) Platelet are stored at 22 degree C -24 degree C in platelet agitator to maintain platelet function. Volume of platelet concentrate is 30-50 ml & volume of PRP 150-170 ml. One unit of Single donor( Aphaeresis platelet) has a volume 150-300ml. Platelet are to be transported in a blood transport box that keeps the temperature at about 20 degree C – 24 degree C. DO NOT REFRIGERATE the platelet. Transfuse platelet as soon as possible. When ever large quantities of platelets are required for special procedure inform the BTS at least 24 hours in advance. Platelet concentrate of any group can be transfused to any group patient, but PRP has to be group specific. It is stored at -40 degree C or lower. The volume of cryoppt is 25-30 ml. It is thawed at 30 degree to 37 degree C water bath which takes about 15-30 minutes. Once thawed it should be transfused within 30 minutes. If not immediately transfused it is kept at 2 degree C- 4 degree C & can be transfused within 4 hours of thawing. It can not be refrozen, if not transfused, it has to be discarded. Issue of blood/components In order to avoid outdating, FIFO policy is implemented in blood bank . issue forms are to be presented at the issue counter. Ensure compatibility testing using has been carried out . Ensure that the compatible units are tested for TTI and found suitable for use Remove the correct unit from blood bank refrigerator and label the unit with the blood issue label. Keep it in the thermal box for transport Make entries in the issue register Instruct the individual to take the unit straight to OT/Ward for transfusion. 5.6 Criteria for reissue of received back blood bags Blood units are checked grossly, for physical changes, like clot formation, hemolysis or discoloration and are kept in quarantine for 24 hours. If supernatant plasma is clear, then these units are to taken for further use in general pool within the expiry date. 6. PRETRANSFUSION ISSUES AND BEDSIDE PRACTICES 6.1 Procedure for Collection of Blood Sample of the Patient for Pre Transfusion testing 1.Blood sample for grouping and cross matching must be drawn by the RESIDENT DOCTOR on duty and not by the Nursing Staff 2. Place only one plain test tube/vacutainer (10 x 100 mm), label with patients name, age/sex, CR number ward/bed number. 3. Take the rack with labelled tube to the patients bed side. For identification of the patient follow the following procedure a) If the patient is conscious at the time of taking the sample ask him or her to identify them self by given name, bed number. b) If the patient is unconscious ask the relative or second member of the staff to verify the patient's identity. Also Confirm the particulars of the patient from the case file. 4. Draw 5 ml of blood and put in Pre-labelled test tube. 5. Recheck the particulars and sign on the label of test tube. 1.DO NOT draw samples from the patient in an unlabelled tube. 2.DO NOT keep more than one tube in the rack. 3.DO NOT collect samples from more than one patient at a time. N.B:- The commonest reason for mismatch transfusion is the clerical errors/wrong labeling of the patient blood samples 6.2 Procedure for Arranging /Requisitioning of Blood/Component from the BTS 1) Send the completely filled blood requisition form along with properly labelled 5 ml blood sample in plain test tube/EDTA 2) Make sure that the policy for receiving routine and emergency blood requisition is 6.3 Getting Blood /Blood Components Issued from BTS for Emergency / Ward/ICU/OT A common cause of transfusion reactions is the transfusion of an incorrect unit of blood that was intended for a different patient. This is often due to mistakes when collecting blood from the blood bank. It is important to follow these instructions. 1) Send the Release form along with the proper thermo col /Ice box for blood issue : Full particulars of the patient for whom the blood/blood component is required should be written in the release form as shown below:  Name of the patient Age/Sex  Ward/Bed Number CR Number  Number of Units required,  Specify the Blood component ie. RBCells, FFP, Platelet Concentrate, 2) Blood for routine cases is issued as & when required (it takes about 15 minutes for issue of pre requisitioned blood). 3) For getting FFP please inform 45 minutes 1 hour in advance of exact time of transfusion. For cryoprecipitate inform 30-45 minutes in advance of exact time of 4) For emergencies blood is issued within 30-45 minutes of receiving requisition. 6.4 Administration of Blood Every hospital should have standard operating procedures for each stage of clinical transfusion process. All staff should be trained to follow them. Clear communication and cooperation between clinical and blood bank staff are essential to ensure the safety of blood issued for transfusion. Once the decision to transfuse has been made, everyone involved in the clinical transfusion process has the responsibility to ensure the right blood gets to the right patient at right time. The main steps in this process are as follow: A Preadministration checks: Step 1: Check the patients notes for- • The component prescribed • Any special requirements e.g. leucodepletion, warming, irradiation etc. • Any pre-medication ordered e.g. diuretic Note: The same process must be repeated for each component administered Step 2: Ask the patient for –Name, Surname, DOB (Date of Birth) • Check these details against the details on the patient's wrist band/compatibility label • Check the patients hospital case file number against the number on the compatibility • Be extra vigilant when checking the identity of the unconscious / compromised patient Step 3: Check the details on the compatibility label against the details on the Unit. Look for: • Blood group – It does not have to be identical but compatible as per the report • Unique donation number – the number on the unit must be matched with that on the compatibility report • Expiry date – Do not use any component beyond the expiry date or time • Type of component – The label on the unit provides information on type and volume of • Signs of deterioration, leaks or clumping Note : Do not proceed if there is any discrepancy at any step and contact the blood bank Step 4 : - Checking the unit of blood The blood pack should always be inspected for signs of deterioration on arrival in the ward. However the staff taking the blood from blood bank should check for any leakage before signing the issue register. 1. Discoloration or signs of any leakage may be the only warning that the blood has been contaminated by bacteria and could cause a severe or fatal reaction when 2. The final identity check should be undertaken at the patient's bedside immediately before commencing the administration of the blood product. It should be under taken by two persons at least one of who should be registered nurse or doctor. • Check that there are no discrepancies between the ABO & Rh-D group on Blood unit Compatibility label and also Check that there is no discrepancy between the unique donation number on Blood pack Compatibility label • Check the expiry date on the blood pack has not been passed. The final check at the patient's bedside is the last opportunity to detect an identification error and prevent a potentially incompatible transfusion, which may be Step 5 Checks on Patient details before starting blood transfusion • Check Patient's baseline vital signs – temperature, pulse, respiratory rate and BP • Record these on the case file • Document time of starting the transfusion Blood bag allowed to warm above 100C if not used BB cannot accept for reuse B) Administration of blood and blood component • Wash hands properly before starting transfusion • Verify special needs e.g. filtration, pooling, warming blood • After final patient identity check and baseline medical check at the bedside, start transfusion • Immediately before transfusion mix the unit of blood thoroughly by gentle • Use standard transfusion set with filters (170 microns) to remove blood clots and other debris • Observe the patient closely for at least 15-30 minutes • Only isotonic saline is recommended to be used with blood components • Do not prime the administration set with 5% Dextrose or Ringer Lactate Solutions; (Dextrose will cause hemolysis of the red cells and calcium in Ringer Lactate will cause clot formation) • Before administering blood completely flush all the incompatible IV fluids • For First half an hour patient must be under direct observation • Rate of Transfusion varies with o Blood volume /urgency of volume replacement o Hemodynamic condition o Cardiac status of recipient o Initially -1 ml / min smaller in pediatric patients - 4 ml/ min after 15 minutes of observation - Pediatric 10-20 ml / kg over 30-60 minutes • Change blood filter every 4 hours • Platelet/FFP/Cryoprecipitate – transfuse within 30 – 60 minutes C) Monitoring of recipient during transfusion: • Patient should be transfused in an area where they can be closely observed and has an access to a call button • The procedure and symptoms of a reaction should be explained to the patient • Encourage the patient to notify the nurse immediately if they begin to feel anxious, or if they experience any of these symptoms • Monitoring should be done for each and every unit of blood or blood components • Frequency of observation- o Before the start of the transfusion o 15 minutes after starting the transfusion o At least every hour during the transfusion o On completion of the transfusion o 4 hours after the completing the transfusion • Recording the monitoring of the patient o Record the patient's vital signs in the patient's case notes/file -Temperature/Pulse/respiratory rate/BP o Fluid balance- oral and IV fluid intake, urinary output o Any adverse effects • Post transfusion monitoring - evidence of improved clinical status (Hematocrit, Platelet count, coagulation factors ), possibility of Delayed Hemolytic Transfusion D) Recording the transfusion: Record the following details in the patient's case notes/file  Type and volume of product transfused  Donation number and blood group of each product/unit transfused  Time at which transfusion started and completed  Change of transfusion set if required  Signature of responsible person for transfusion 6.5 Time limit for infusion Complete infusion Whole blood/Red Cells Platelet Preparations within 20 minutes Fresh Frozen plasma As soon as possible within 20 minutes 6.6 Disposable Equipment for Administration of Blood Cannulas for infusing blood products must be sterile and must never be reused Use flexible cannulas if possible as they are safer and preserve the veins Whole blood / Red cells  Use a new sterile blood administration set containing an integral 170-200 micron  Change the set at least 12 hourly during blood component infusion  In a very warm climate change the set more frequently and usually after every four units of blood, if given within a 12 hours period. 6.7 Paediatric patients Use a special paediatric set for paediatric patients These allow the blood or other infusion fluid to flow into a graduated container build into the infusion set. This permits the volume given and the rate of infusion to be controlled simply and accurately. Red cells should only be warmed using a specifically designed commercial device with a visible thermometer and audible warning. Blood components must not be warmed using improvisations such as putting the pack into hot water, in a microwave or on a A blood warmer is indicated 1. When blood is transfused a) at flow rates of > 50ml/kg/hour in adults b) at flow rates of 15ml/kg/hour in children For exchange transfusion in infants Transfusion of patients with clinically significant cold agglutinins Blood and blood components should not be warmed above 370C 2. Operating temperature of a blood warmer should be recorded on the patient's infusion record when used to warm red cells or blood products 3. Blood warming devices should undergo at least a 12 monthly maintenance and validation program Concurrent fluids and medications 6.9.1 Concurrent fluids The only fluids that can be given concurrently through the same IV line as a red cell  ABO compatible plasma  Plasma protein fraction Incompatible fluids  Electrolyte and colloid solutions containing calcium (e.g. Haemacel, Gelofusine) should never be given with blood or blood components as they may cause clotting of the infusion line  5% Dextrose in water or hypotonic sodium solutions may cause red cells to  Other solutions shall not be given with red cells unless there is sufficient data to ensure compatibility. 6.9.3 Medications Medications should not be added to the blood bag or the transfusion line. If drugs need to be administered via same IV line, the transfusion should be stopped and the line flushed with normal saline. After administration of the drug, the line needs to be flushed again with normal saline before restarting the transfusion. This procedure should not result in the transfusion of red cells exceeding 4 hours. Role of the Hospital Transfusion Committee (HTC) • A hospital transfusion committee should be established in every hospital. • HTC monitors the safety, adequacy and reliability of the supply of blood, blood products and IV fluids • Also monitor the usage of blood and blood products through developing guidelines for appropriate clinical use of blood and blood component & ensuring training to staff. • Review incidences of adverse reactions, errors, taking corrective/preventive action where necessary • Plan the future needs 6.10.1 Safe transfusion practices:  The BTS/blood bank should ensure that the hospital has SOPs in place for all stages of the clinical transfusion process and that all staff are trained to follow  Procedures for the correct identification of the patient, sample and product are  Morbidity and mortality resulting from the transfusion of incompatible blood components is due to human error. It is entirely preventable if a quality system • Safe transfusion depends on: • Accurate, unique identification of patient • Correct labeling of the blood sample • Final check of patient, product and documentation at patient's bedside • Correct storage conditions of blood & blood component • Use within correct time limits • Inspection of the unit before transfusion 7. TRANSFUSION REACTIONS It is any unfavourable transfusion related event occurring in a patient during or after transfusion of blood or blood components. 7.1 Classification: A. Immune mediated reactions Immediate (< 24 hours) Delayed (> 24 hours) 1. Hemolytic transfusion reaction (HTR) 1. Hemolytic (DHTR) 2. Febrile Non-hemolytic (FNHTR) 2. Allo-immunization 3. Allergic reactions 3. Post transfusion purpura (PTP) 4. Anaphylaxis and Anaphylactoid 5. Non-cardiogenic pulmonary edema B. Non Immune mediated reactions Immediate (< 24 hours) Delayed (> 24 hours) 1. Bacterial Contamination 1. Iron Overload 2. Circulatory Overload 3. Depletion / dilution of coagulation factors or platelets 4. Physical / chemical damage to RBCs 7.2 Signs and symptoms of a transfusion reaction include 1. Fever with or without chills (temperature > 20F of the base-line body temperature); most common feature in any transfusion reaction. 2. Rigors with or without fever. 3. Pain at infusion site or in the chest, abdomen or flanks. 4. Sudden change in B.P. above or below 30 mm Hg of pre-transfusion level. 5. Respiratory distress (dyspnoea, tachypnea, wheezes). 6. Skin changes including urticaria, pruritus, and localized edema. 7. Nausea with or without vomiting. 8. Darkening or cola-colored urine may be the earliest evidence of acute hemolysis in an anesthetized patient. 9. Uncontrolled bleeding or other manifestations suggestive of disseminated intravascular coagulation (DIC). 7.3 Hemolytic Transfusion Reactions 1. Immune mediated 2. Non Immune mediated 7.3.1 Immune mediated a) Intravascular destruction of transfused RBCs b) Extravascular destruction of transfused RBCs Intravascular destruction • Mainly due to IgM antibodies e.g. ABO antibodies • Activates complement through the classical pathway leading to rupture of RBCs • Most severe and life threatening reactions Extravascular destruction • Mainly due to IgG antibodies e.g. Rh, K, Jk and Fy antibodies • IgG coated red cells interact with the Fc receptors on macrophages of liver and spleen • Rarely severe and life threatening reactions occurs. They are due to: • Primary allo-immunization – Develops antibodies after antigenic stimulation in • Secondary allo-immunization or anamnestic response – In this preformed antibodies in the recipient which cannot be detected due to low levels by the pre transfusion compatibility testing procedures. These antibodies can rise in titer within 72 hours if there is a subsequent antigenic stimulus. Errors leading to hemolytic transfusion reactions 1. Clerical Errors • Inadequate or incorrect labeling of blood i.e. recipients pre transfusion sample, blood bag or pilot tube. • Improper identification of patient either at the time of sample collection or transfusion of blood. 2. Technical Errors • Error in blood grouping of recipient or donor. • Incompatibility not detected in cross matching procedure due to improper • Destruction of recipient RBCs by donor antibodies, due to indiscriminate use of group O blood. • Failure to detect weak antibodies. 7.3.2 Non Immune mediated hemolysis 1. Bacterial contamination 2. Mechanical trauma associated with infusion e.g. transfusion through narrow 3. Equipments that damages RBCs extra corporeally e.g. pressure pumps 4. Thermal trauma e.g. heat or cold 5. Reconstitution of RBCs with hypotonic solutions 7.3.3 Allergic transfusion reactions Mechanism: Preformed IgE antibodies in the patient reacting with soluble donor 7.3.4 Anaphylactic reactions Mechanism: Preformed anti IgA antibodies in IgA deficient individuals 7.3.5 Anaphylactoid reactions Mechanism: Patients often have normal levels of IgA but have pre-formed subclass, allotype anti IgA antibody to IgA present in donor's plasma. 7.3.6 Post transfusion purpura Definition: Severe thrombocytopenia (platelet count < 10,000 / μl) occurring 7-14 days post-transfusion in previously pregnant or transfused patients. A. Anti HPA 1a antibody present in HPA 1a negative individuals B. This antibody destroys not only transfused HPA 1a positive platelets, but patients own HPA 1a negative platelets (Innocent bystanders) because: 1. Recycled or solubilized antigen are adsorbed on patient's self platelets 2. Destruction mediated through antigen antibody complex 3. This antibody may be a cross reacting antibody 7.3.7 TRALI or Non-Cardiogenic Pulmonary Edema (NCPE) In this there is acute respiratory insufficiency and/or X-ray finding consistent with bilateral pulmonary edema with no evidence of cardiac failure (normal pulmonary capillary wedge pressure) usually in 6 hours post transfusion. 1. One Hit model theory – Leuco-agglutinating antibodies (HLA, granulocyte or monocyte specific antibodies) in the donor's plasma leading to complement activation after formation of immune-complexes. C5a causes leucocyte aggregation, which releases oxygen radicals leading to endothelial damage and capillary leakage. 2. Two Hit model theory – Recently described theory proposes that patient's underlying condition (sepsis, trauma) causes priming of neutrophils by lipopolysaccharide, which get activated on transfusion of specific immunoglobulins, lipids or cytokines. This activation causes respiratory burst of proteases causing endothelial injury. 7.3.8 Transfusion Associated GVHD (TA-GVHD) Fatal immunological transfusion reaction(95-98% mortality) associated with engraftment and clonal expansion of donor lymphocytes in susceptible host leading to dermatitis, erythroderma, hepatitis, secretory diarrhoea and pancytopenia. Factors that determine outcome in TA-GVHD includes • The degree to which the recipient is immuno-suppressed • Degree of HLA similarity between the donor and recipient – One way HLA match in which the donor is homozygous for a HLA haplotype for which the recipient is • Number of transfused viable T- lymphocytes. 7.4 Evaluation of acute transfusion reaction Medical personnel attending the patients are generally first to suspect a transfusion reaction and first to take action. In case of any transfusion reaction: 1. Transfusion should be stopped immediately, keeping the intravenous line patent by starting a normal saline drip. 2. All labels, forms and patient identification should be re-checked to make sure whether the transfused component is intended for the recipient. 3. Transfusion services physician and patient's physician should be informed immediately. Physician should evaluate the nature of reaction and act 4. In suspected cases of major adverse event, the following should be sent to the Department of Transfusion Medicine / Blood Bank laboratory for • Post-reaction blood samples must be carefully drawn (preferably EDTA vial) to avoid mechanical hemolysis and properly labeled. • Transfused bag along with its contents and blood transfusion set should 7.5 Laboratory Investigations Four essential steps should be done immediately 1. Recheck for clerical errors / Identification errors A. Details of patient's sample, the blood &blood component issued are to be B. If any discrepancy is found, immediately inform patient's physician, retrieve back all the non transfused units and partially transfused units. This will help to prevent incorrect issue of other blood component which can put other patients at risk. 2. Visual check for hemolysis a) Serum/plasma: post-transfusion reaction sample is examined for any discolouration and increased yellowish tinge. Intravenous hemolysis as little as 5- 10ml of red cells may produce visible hemoglobinemia. Faulty sample collection may also cause mechanical hemolysis, so if it is suspected ask for second b) After 5-7 hrs of acute hemolytic episode, increased unconjugated bilirubin in serum may give yellowish discoloration as compared to pre-transfusion sample. c) Fresh post-transfusion urine for hemoglobinuria d) Blood sample from the bag should be checked for hemolysis. 3. Serological check for compatibility Indirect Antiglobulin test (IAT) • ICT of patient's pre-transfusion sample with donor bag sample to recheck for • In post-reaction EDTA sample Direct Antiglobulin Test (DAT) is performed. If post - transfusion sample DAT is positive; DAT is performed with pre-transfusion sample. • In non-immune hemolysis (viz. mechanical, thermal trauma, osmotic lysis of RBCs) hemoglobinemia is positive but DAT is negative. Also look for any circumstantial evidence for hemolysis. • In suspected sepsis blood culture from the implicated unit and recipient's blood (collected aseptically in proper culture bottle) is to be sent for bacteriological 7.6 Precautions to Avoid Transfusion Reactions • Avoidance of clerical errors • Proper identification of patient • Correctly labeled blood samples for blood grouping and cross matching • Proper identification of the recipient and the blood pack at the time of starting • Careful & close observation of the patient during transfusion • Avoid unnecessary blood transfusion 8. QUALITY MANAGEMENT IN BLOOD TRANSFUSION SERVICES The aim of quality assurance in blood transfusion service is to ensure the provision of safe transfusion of blood and its products. Need of Quality in Blood Transfusion Services Blood bank is the only laboratory directly responsible for the patients with no intervening physician interpretation, so any mistake in blood transfusion service can be disastrous. In order to prevent mistakes, it is essential to have adequate quality assurance in blood transfusion services QMS in BTS is needed to achieve • Safe & adequate blood supply • Appropriate & effective use of blood • Prevention of errors & risks • Protection of donors, recipients & staff • Self sufficiency • Confidence in the system of all concerned  Public- potential donors/recipients  Regulatory authorities  Management & staff 1. Drugs and Cosmetics Act and Rules 1940 (along with Amendments), Sections XB and XIIB, Ministry of Health & Family Welfare Govt. of India. 2. Standards on Blood Banks/ Blood Centres and Transfusion Services. 1st edition(2007), 3. AABB Technical Manual, 17th edition (2010), AABB Press, USA. 4. Clinical Use of Blood. World Health Organization, Blood Transfusion Safety, Geneva, recommendations. World Health Organization, Geneva, 2009. 5. Barbara John. Viruses. Vox Sanguinis 2004, 87 (supplement 1), S91 – S94. 6. Busch M, Kleinman HH, Nemo GJ. Current and emerging infectious risks of blood transfusions. JAMA 2003, 289: 959 – 962. 7. Manual on HIV testing in laboratories. NACO, 2007 1. Donor Questionnaire 2. Donor Informed Consent form (ii) Donor reactions 4. Transfusion Reaction Form 5. Lectures for training of Nurses ANNEXURE 1: BLOOD DONOR QUESTIONNAIRE Donor Questionnaire Thank you for coming forward to donate blood To ensure your safety as a blood donor and the safety of the patients who will receive your blood, please read the information leaflet provided and answer this questionnaire correctly. If you have any difficulty in filling this form please ask for help from the Blood Centre Staff. All details given by you will be kept confidential. Date Of Birth:……………………………………. Blood Group:…………. 1. Have you donated blood previously? 1.1 If yes how many times 1.2 Date of last donation: 1.3 Did you experience any ailment, difficulty or discomfort during previous donations? 1.4 What was the difficulty? 1.5 Have you ever been advised not to donate blood? 2.1 Are you feeling well today? 2.2 Have you eaten anything in the last 4 hours? 2.3 After donating blood do you have to engage in heavy work, driving heavy vehicle or work at heights today? 3. Have you had / have any of the following? If yes, discuss with the doctor present: • Kidney disease • Endocrine disease • Mental illness Fainting attacks • Blood / Bleeding disorder • Tuberculosis • Liver disease • Skin disease • Polycythemia • High /Low Blood Pressure • G - 6 PD deficiency 4. During past 12 months have you had any of the following? 4.1 received blood or blood components? 4.2 any accidents or operations received any vaccinations 4.4 bitten by any animal, which can result in rabies? 4.5 had tattooing / ear piercing or acupuncture treatment? have you been imprisoned for any reason? 5. Have you had jaundice in the last 1 year? 5.1 Has your blood ever tested positive for Hepatitis B or C? Have you had close contact with anyone (family/ others) suffering from jaundice in the last 1 year? 6. Have you had tuberculosis or typhoid during the last year? 7. Have you had malaria or taken anti malarial drugs in the last 3 years? Yes No 8. Have you had any of the following in the last 6 months? Dental Procedure 9. Have you taken any medicine in the last 7 days esp aspirin or antibiotic 10. Do you know that you should not give blood in following conditions? If you were found to be positive for HIV, Hepatitis B, C or Syphilis infections If you are having multiple sex partners or have engaged in male to male sexual activity If you have ever worked as a sex worker or had sex with a sex worker If you have ever injected any drug (esp. Narcotics) not prescribed by a qualified doctor • If you suspect that you or your partner may have HIV or any other sexually transmitted disease Do you or your sexual partner belong to one of the above categories? 11 .1 Do you have any reason to believe that you have been infected by the virus that 11.2 In the last 6 months have you had:Night sweats Persistent diarrhoea Persistent fever Unexplained Weight Loss In case you are a woman: a. Are you pregnant or have you had an abortion in the last 6 months? Yes No Have you a child less than 1 year of age? Are you breastfeeding? Yes No For Office Use Only Name of medical officer: Weight:…………………kgs Hb level: > 12.5g/dl < 12.5g/dl Feeling well? / Adequate sleep (>5hrs)? / Last meal within 4hrs? History check list: Ever hospitalized? Current illnesses or medications: Unhealthy look? / Palor, lcterus? / Alcohol smell Infected wounds / Venepuncture site lesions Examination check list: Pulse:………….beats/min BP:……………. mmHg Heart: ……. Lungs:……………. Post donation instructions / Making a regular donor Need for follow up for TTI purposes. Counseling points How to contact for follow up purposes: By a letter By phone Donor accepted Temporary deferral Permanent deferral Remarks / Reasons for Deferral: NAME of Registering Officer: Blood Unit No.:- Type of Bag:- Single. Double.: Triple.: Quadruple.: BLOOD COLLECTION Name of phlebotomist: Check: Donor's Name Check Donation No: On Donation record / Blood Bags / Specimen Tubes Start time:……………. a.m./ p.m. Time Taken :……………mins. Volume:……………ml Complications: Faint: Fits: Double Prick Haematoma: Others (please specify): ANNEXURE 2: BLOOD DONOR INFORMED CONSENT FORM • I declare that I have read and understood the information regarding blood donation and answered all the above questions honestly and correctly. • I agree that the blood donated by me voluntarily will be used for the benefit of the patients, in any manner as decided by the Blood Centre. • I also agree to follow the instructions given to me by the Blood Centre, during and after blood donation and accept the responsibility of any consequences of not following those instructions. • I give my consent to test my donated blood for HIV 1 and 2, Syphilis, Hepatitis B and C, Malaria and any other required test in any manner deemed appropriate by the • I would like to informed about any abnormal test result : Yes No Mode of communication : Letter Phone Mobile e-mail I AM WILLING / NOT WILLING TO DONATE BLOOD ONCE / TWICE / THRICE A YEAR TO SAVE MANY MORE HUMAN LIVES! Donor's Signature :……….…….….… (To be signed in front of the interviewing Officer) Date: - ………………. ANNEXURE 3 (i): QC of CuSO4 QC of Working CuSO4 Solution Specific gravity Specific gravity <12.5 >12.5 Specific gravity of distilled water (DW) Specific gravity of copper sulphate (CuSO4) 1.053 (12.5gm/dl Hb) Known controls to be obtained very week from laboratory of hematology QC to be performed once a Sign of technologist /MO ANNEXURE 3 (ii): Donor Reactions Donor Reactions Report Donation date & time : _Name Age / Gender Weight Unit ID Type of Donation : replacement/ Voluntary/ WB/ Apheresis Donation Status : First time/ repeat (no) Volume collected : Donor Reaction Details: (Circle all that apply)  Location: Examination room/phlebotomy room/refreshment room/others _  Time: before donation/during donation/after donation  Symptoms: dizziness/ light headedness/ nausea/ weakness/ difficulty in breathing/ tingling/ numbness  Signs: pallor/diaphoreses/nervousness/vomiting/ incontinence/hypotension/muscle twitching/ hyper ventilation/ bradycardia/ tachycardia/ LOG _sec/ min. Others  Action Taken: donation discontinued / feet elevated / encouraged fluid intake / donor chair reclined / assisted to floor / cool compress / ammonia inhalation / others _ Pulse (Beats/ min H/ O previous reaction: yes/no if yes Level mild/ moderate / severe Reaction level: 1/ 2/ 3 Advise for future donation: yes/no/ others Other donor complications: Hematoma Size : _ _Ice applied/ pressure bandage applied/ others Arterial puncture : Bandage allergy: Recovery period : _min Discharge time : Sign of personnel attending donor In charge signature ANNEXURE 4: Transfusion Reaction Form 1. Patient Details: Name Cr. No. Age/ Sex _ Ward/ Bed _ C / I Resident I/C Blood Group (as per record) Clinical Diagnosis _ 2. Patient's History/ Examination: H/ O previous transfusion reaction: yes/ no. If Yes: Date _ No of Unit Obstetric history H/ O atypical antibody in serum _ Pre- transfusion Hb Level Vol. Of urine passed (post transfusion) 3. Transfusion Details: Computer reg. No Blood Bank No. Indication for transfusion _ Cross match by Component issued (Name/ No) _ Date / Time of Issue _ Component transfused: Blood/ RDP/ SDP/ FFP/ CPP/ CRYO _ Date and time of starting transfusion Date and Time of Reaction _Vol. Of product transfused _ Blood / Component was stored in: Freezer/ Refrigerator/ Room Temperature H/ O warming: Yes/ No. Method: water bath/ microwave/ 37o incubator/ direct heater. H/ O Injection in blood bags: Saline Dextrose/ Distilled water/ Ringer Lactate 4. Reaction Details: Type of reaction: Immediate/ Delayed: Fever _ Chills _ Rigors Rash _ Lumber pain Tachycardia Hypotension _ Vomiting _ Hemoglobinuria Jaundice _ Oozing from puncture marks Pallor/ Cyanosis Pain at infusion site _ Others 5. Check for labeling discrepancy  Pre Transfusion  Post Transfusion Requisition form Cross match Report 6. Check Blood Bag For Volume of blood left Colour of red cell Colour of Plasma Muddy Red/ Clear Any abnormal mass or clot Any peculiar odour Leakage/ Breakage 1 broken/ 2 broken Transfusion set filter Present / Absent Bacterial and Fungal culture 7. Serological Testing: I. Colour of plasma III. Antibody screening Enz / Alb Method IV. Repeat cross match a. Pre transfusion sample b. Post transfusion sample V. Other post transfusion investigations a. Serum Bilirubin b. Serum Heptoglobulin f. Platelet count g. Coagulation profile Transfusion Unit Type of Reaction Non Hemolytic: Type ANNEXURE 5: Lectures for training of Nurses (presentations available in CD) Donor Area – all 5 Bedside practices Transfusion reactions Stock management

Source: http://indiahivinfo.naco.gov.in/sites/default/files/media-gallery/training_module_for_nursec_in_blood_bank-F.pdf

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Ind. J. Sci. Res. and Tech. 2013 1(1):53-61/Gowdaiah et al ISSN:-2321-9262 (Online) Online Available at: http://www.indjsrt.com Research Article PLASMA LIPIDS AND HIGHLY ACTIVE ANTIRETROVIRAL THERAPY; A PROSPECTIVE STUDY *Prakash Kikkeri Gowdaiah1, Rajiv Elkal Neminatha2, Madhu Sudan Channappa1, Sandeep Sreerama

Acs_ar_ar-2012-00176y 1.9

Lithium Insertion in Nanostructured TiO2(B) ANTHONY G. DYLLA, GRAEME HENKELMAN, AND KEITH J. STEVENSON* Department of Chemistry & Biochemistry, The University of Texas at Austin, Austin, Texas 78712, United States RECEIVED ON JUNE 12, 2012 to become feasible alternatives to current technology, but only if scientists can develop energy storage materialsthat offer high capacity and high rate capabilities. Chemists havestudied anatase, rutile, brookite and TiO2(B) (bronze) in bothbulk and nanostructured forms as potential Li-ion batteryanodes. In most cases, the specific capacity and rate of lithiationand delithiation increases as the materials are nanostructured.Scientists have explained these enhancements in terms of highersurface areas, shorter Liþ diffusion paths and different surfaceenergies for nanostructured materials allowing for more facilelithiation and delithiation. Of the most studied polymorphs,nanostructured TiO2(B) has the highest capacity with promising high rate capabilities. TiO2(B) is able to accommodate 1 Liþ per Ti,giving a capacity of 335 mAh/g for nanotubular and nanoparticulate TiO2(B). The TiO2(B) polymorph, discovered in 1980 by Marchand andco-workers, has been the focus of many recent studies regarding high power and high capacity anode materials with potential applicationsfor electric vehicles and grid storage. This is due to the material's stability over multiple cycles, safer lithiation potential relative to graphite,reasonable capacity, high rate capability, nontoxicity, and low cost (Bruce, P. G.; Scrosati, B.; Tarascon, J.-M. Nanomaterials for RechargeableLithium Batteries. Angew. Chem., Int. Ed. 2008, 47, 2930"2946). One of the most interesting properties of TiO2(B) is that both bulk andnanostructured forms lithiate and delithiate through a surface redox or pseudocapacitive charging mechanism, giving rise to stable high ratecharge/discharge capabilities in the case of nanostructured TiO2(B). When other polymorphs of TiO2 are nanostructured, they still mainlyintercalate lithium through a bulk diffusion-controlled mechanism. TiO2(B) has a unique open crystal structure and low energy Liþ pathwaysfrom surface to subsurface sites, which many chemists believe to contribute to the pseudocapacitive charging.