Correct Procedure for Blood Transfusion and Transfusion of Blood Products

Correct Procedure for Blood Transfusion and Transfusion of Blood Products

First see this news report from http://www.tribuneindia.com/2011/20110622/cth1.htm#4

Chandigarh, June 21
The police on Tuesday arrested two doctors involved in the case in which a 28-year-old patient, Suman Devi, was administered wrong blood resulting in the death of her foetus and damage to her kidneys last year.

Dr Navdeep, an intern, and Dr Manpreet Kaur, a house surgeon at the Government Multispecialty Hospital, Sector 16 gave themselves up at the Sector 17 police station following which they were taken into custody. Both were booked under sections 211 (destroying evidence) and 304A (death due to negligence) of the Indian Penal Code but were later released on regular bail.

The police filed an FIR (first information report) in the case on June 14 after a magisterial probe found both doctors guilty of negligence. A third suspect, Kirti Sood, a lab technician at the hospital, is yet to be apprehended, the police said.

On December 16 last year Devi was admitted to the hospital’s gynecology ward and given a wrong blood transfusion that led to acute renal (kidney) failure. Due to a low hemoglobin level she was then given a unit of blood the same morning. Though her blood type was A positive she was given a unit of B positive blood that was meant for another woman, whose first name was also Suman.

After the blunder came to light Devi was referred to PGI but by that time her foetus had already died. A magisterial inquiry was marked and the report concluded Sood had issued the blood bag without crosschecking for the patient’s necessary details, particularly about her blood type. Later on she concealed the facts and tampered with the blood samples, the report added.

The report stated Navdeep initiated the blood transfusion for the patient without checking and rechecking the patient’s necessary details and began the transfusion on the presumption that the blood bag lying beside the patient was meant for her, violating all the fundamental blood transfusion protocols.

The report further stated that without even checking details on the blood bag, Manpreet passed on the responsibility for the blood transfusion to her amateur junior colleague who also failed to follow up and monitor the patient.

This has many issues like Role of Interns, Residents and House Surgeons, and who is accountable etc, but, let’s discuss Transfusion first in this post

Doctors are SELDOM taught how to handle drugs as a part of the curriculum

Many learn it the hard way, when either they get into problem or when one of their friends get into problem

The following procedure should be followed scrupulously

1. Decision on Transfusion should be first made and the following points to be decided when decision to transfusion is made. This is the duty of the Treating Doctor
   • What is the indication for transfusion : The correct indication for transfusion needs to be ascertained . Transfusion has so many complications, acute and chronic, infective and non infective, immune mediate and non immune mediated that unless indicated, transfusion should be me ordered as a matter of routine.
   • What is the product to be transfused : Whole blood is hardly indicated, except for few specific purposes. Many patients require only packed cells, some may require specific components and some may not require blood at all and a pint of normal saline may be enough
   • When should the transfusion be done : Unless it is acute / emergency (eg Trauma, PPH) , transfusions of most other conditions (eg Anemia Correction) should be done in the day shift or morning shift when there are  more people in blood bank to do cross matching, more people to transport blood, more hands to transfuse and  more hands to maintain complications, if they occur.
   • Pre Transfusion Blood Hemoglobin, PCV
   • Check for Cardiac Status
   • Write the Requisition
2. Sample for Cross Matching, The following are the duty of the Ward Staff Nurse or in case of Operation theatre, the Anesthesiologist
   • First step is to check whether the iv cannula is working. If there is no cannula, a new iv cannula (venflon) is inserted and samples are taken while inserting a venflon
   • Blood is transfused using blood needle. Then Why is Venflon Needed ? It is needed because, in case of transfusion reactions, emergency drugs like Avil, Hydrocortisone (and adrenal if needed) are to be administered. An iv cannula which is functioning and which is without block is needed. So, insert a cannula and take sample
   • Label the Blood immediately with Patients Name, Age, Sex, Blood Group, IP Number, Ward Number and make sure that the details in the requisition, case sheet, sample label are identical
3. Transport of Sample + Requisition to Blood Bank. This is the duty of the MNA / Staff Nurse or any other hospital staff
4. Procedures in Blood Bank
   • Decision on number of bags to be given : Duty of the Blood Bank Medical Officer
   • Cross Matching of  the RBCs of Donor Blood and Serum of Recipient Blood is to be done by the Authorised Staff in Blood Bank
   • The Authorised Staff in the Blood Bank, enters the detail in the registers in Blood Bank and the Blood Bag Number in the Case Sheet.
   • Blood Bags must be received from the Blood Bank by the authorised person.
   • The person who receives should check that the number of the case sheet issue seal and the number on the bag are the same.
   • When some one who receives a blood bag signs in the issue register in the blood bank, he or she acknowledges that the Serial Number (and Group) in the Blood Bag and the Serial Number noted in the case sheet are the same –> How many of the house surgeons know this ??
5. Transport of Blood Bag to the Ward from the Blood Bank. This is the duty of the MNA / Staff Nurse or any other hospital staff
6. Transfusion is done by the Ward Staff Nurse or in case of Operation theatre, the Anesthesiologist
   • Verification of the Blood Group
   • Verification of the Blood Bag Number with the one written in the case sheet
   • Verification of Name. Age, IP Number etc, if they are given by Blood Bank
   • Give Injection Avil + Decadran iv (protocol may vary from center to center)
   • Measure Blood Pressure and Pulse Rate and enter in the Case Sheet (to be used as Baseline)
   • Use the Transfusion set (not routine iv set) for transfusion of Blood / Packed Cells. Large bore iv cannulas can also be used
   • Mention the time of starting the transfusion in the Case Sheet
   • Be near the bed side for the first 5 minutes
   • Examine the patient and look for tachycardia, tachypnea, rashes, c/o itching, Hematuria, Bleeding from Gums every five minutes for the first half hour and every 15 minutes after that till transfusion is completed
7. After completion of transfusion
   • Note the details in the case sheet
   • Flush the IV Cannula or Central Line with 20 ml Saline
   • Preserve the Blood Bag and Transfusion kit
   • Examine the patient and look for tachycardia, tachypnea, rashes, c/o itching, Hematuria, Bleeding from Gums every hour for the next 24 hours
   • Do a CT / BT after 6 hours and after 24 hours
   • If there are no symptoms and signs of reaction, dispose the Blood Bag and Transfusion kits as per Biomedical Waste Management Protocolsa
8. In case of Reaction
   • Stop Transfusion immediately
   • Give Hydrocortison, decadran, avil (dosages and other drugs as per institution protocol)
   • Inform the Superiors immediately – till unit Chief and further management as per their advice
   • Inform the Blood Bank by Phone immediately
   • Collect  Blood Bag and Transfusion kits and send to Blood Bag in the prescribed formats
   • Mention the details in Case Sheet
9. In case of prolonged CT / BT after transfusion 
   • Inform the Superiors immediately – till unit Chief and further management as per their advice

Feel free to ask doubts / clarifications in the comment Section

Update :

Chandigarh: Faced with the prospect of imprisonment for violating orders in a consumer case, an officer of Chandigarh’s health department on Monday paid Rs 4.38 lakh in compensation to a woman who lost her foetus and suffered kidney damage.

The loss of the foetus and the kidney damage occurred because of the negligence of government doctors in a leading hospital here.

Government Multi-Specialty Hospital (GMSH) medical superintendent Dr Rajiv Wadhera appeared in person before the Chandigarh State Consumer Commission and tendered an amount of Rs 4,38,515 to the victim, identified as Suman.

The commission had summoned Dr Wadhera, who was acting Director – Health Services, to explain why the compensation was not paid to the victim despite its order of March 2012.

The commission had given time to the health department till Sep 27 to pay the amount.

Suman, who was pregnant, suffered at the hands of three negligent doctors who got blood of a wrong group administered to her in the GMSH in December 2009.

The blood group was meant for another pregnant woman.

Suman, as a consequence, lost her foetus and suffered damage to her kidneys.

The commission had ordered that the hospital and the team of doctors and technician — Kirti Sood (lab technician), Dr Navdeep Kaur (intern) and Dr Manpreet Kaur (house surgeon) — pay the patient compensation, according to Suman’s counsel Pankaj Chandgothia.

Dr Wadhera, in an affidavit to the commission, had earlier stated that the full compensation was not paid to Suman as the doctors had left government service and that the health department had no means to recover costs from them.

The GMSH offered to pay only one-fourth of the compensation amount, saying that it was only one of the four parties.