T ransfusion Services

T ransfusion Services International institute of Health Management Research, Delhi MinakshiGautam Assistant Professor

History of Blood Bank • Early development leading to establishment of banks dates back to 1915. • It was when Richard Lewison of Mount Sinai Hospital, New York initiated the use of sodium citrate as an anticoagulant. • This discovery transformed the blood transfusion procedure from direct (vein to vein) to indirect. • The introduction of a citrate-glucose solution by Francis Peyton Rous and JR Turner 2 years later permitted storage of blood in containers for several days. • Thus opening way for the first “blood Depot” established in Britain during World War I.

History of Blood Bank • Within a few years, hospital and community blood banks were established across United States. • Willem Johan Kolff organized the first blood bank in Europe (in 1940) • An important breakthrough came in 1939-40 when Karl Landsteiner, Alex Wiener, Philip Levine, and R. E. Stetson discovered theRh Blood group system, which was found to be the cause of majority of transfusion reactions upto that time.

History of Blood Bank • Three years later, the introduction by J.F. Loutit and Patrick L. Mollison of acid-citrate-dextrose (ACD) solution, which reduces the volume of anticoagulant, permitted transfusions of greater volumes of blood and allowed longer term storage. • An anticoagulent preservative, CPDA-1 was introduced in 1979. • It decreased wastage from expiration and facilitated resource sharing among blood banks. • Newer solutions contain Adenine and extend the shelf life of red cells to 49 days.

Definition The transfusion services can be defined as “A medical facility, designed, equipped and staffed, to procure, draw, process, and store and distribute human blood and its derivatives.” (American Association of Blood Banks)

Some Facts • Millions of lives are saved each year through blood transfusions. • In many countries, people still die due to an inadequate supply of blood and blood products. • To maintain an adequate blood supply, 1-3% of the population needs to be blood donors.

Some Facts • More than 92 million units of blood are collected globally every year. (WHO 2012) • Nearly 50% of these blood donations are collected in high-income countries, home to 15% of the world’s population. • However only 45% of these are donated in developing and transitional countries where more than 80% of the world’s population lives. • Where blood is available, it is often unsafe.

Some Facts • WHO estimates that the lack of effective screening results in up to • 16 million new infections with hepatitis B, • 5 million new infections with hepatitis C • 16,000 cases of HIV infections every year • Overall, 5-10% of HIV infections worldwide are the result of transfusions of contaminated blood or blood products.

Some Facts • Hence every country has a common need to ensure; • Availability of adequate supplies of blood and blood products and their accessibility to all patients requiring transfusion; • Safety of blood and blood products; • Safe and appropriate clinical use of blood and blood products

Some Facts • During last two decades there has been an increased awareness in the field of blood transfusion medicine. • This is due to advances in basic medical sciences such as immunology, biotechnology, genetics, cryobiology, physiology as well as technical progress. • Greater stress has been laid on voluntary blood donation.

Some Facts • The major aim of blood transfusion has been to make transfusion safe. • Other aims have been in prolongation of the shelf life of blood. • It’s optimum utilization. • Development of synthetic substances to supplement human source.

Some Facts • Through better understanding of red cell metabolism, the red cell preservatives can preserve the red cells upto49 days as against 21 days earlier. • The emphasis is now rightly put on the use of various components of blood • This helps to utilize one unit of donated blood for more than one patient.

Some Facts • Therapeutic applications of cell separators have also enabled clinicians to reduce morbidity and mortality. • More sensitive methods for screening have helped in prevention of diseases like hepatitis B, C and HIV/AIDS. • Methods of HLA (leukocyte antigens) typing have been useful for transplant surgeries.

Some Facts • Efforts are being made for use of artificial substitute for specific components of blood. • Genetic engineering techniques have isolated recombinant DNA clones for adequate and safe production of plasma proteins especially factor VIII. • The most important managerial issue of a blood bank is the donor recruiter and bleeding donors.

Some Facts • Ideally no blood or blood components should be allowed to outdate. • Every effort should me made to reduce the waste of blood. • As per the available data, the wastage due to outdating of blood is to the tone of about 10%, which is a significant in the light of such a scarce commodity.

General Considerations • The blood transfusion centre should be located where it provides easy access for donor and staff, • And allow quick and safe transportation of blood and components to hospitals Tasks of Transfusion Centre and Planning a facility • Total amount of blood to be taken • The level at which centre will operate (national, regional, district)

Functions of Blood Bank • The main functions of the blood bank are; • Recruitment of donors and maintenance of donor’s record. • Collection, preservation, and distribution of blood and blood components. • Laboratory procedures like, testing for hepatitis B, Hepatitis C, HIV, VDRL for Syphilis and Malaria Parasite. • Teaching, training and research • Clinical and therapeutic functions like transfusion and daycare service.

Functions of Blood Bank • Organizing of outreach programs for blood donation camps in the community on a regular basis. • Community Awareness programmes in close liaison with mass media for motivating people to donate blood. • Awareness program for treatment of hematological disorders like Hemophilia, Thalessemia, etc. • Community Awareness Programs for transfusion transmitted diseases. • Maintaining a database for various types of blood groups; particularly rare blood groups; with details of contact telephone numbers or email ID, etc.

BLOOD COMPONENTS • Packed Cells • Fresh Frozen Plasma • Single Donor Plasma • Cryoprecipitate • Hemoglobin • Factor VIII concentrate • Factor IX concentrate • Platelet rich plasma • Platelet concentrate

How long can the blood be stored at blood bank? • Whole blood can be stored for 35 days. • The various blood components can be stored as under; * Platelet Concentrate - 5 days * Packed Cells - 42 days *Fresh Frozen Plasma – 1 year * Cryo Anti Hemophilic Factor – 1 year • Deep Freezer (-40°C and -80°C) are used to preserve plasma, related blood components while platelets are store in agitator machine at 20°C for proper storage.

Indications • Packed Cells: Severe Anaemia and edema, chronic leukemia, hemolytic anemias, etc. • Fresh frozen plasma: Inborn deficiency of coagulation factors, DIC, Thrombocytopenic purpura • Cryoprecipitates: Chronic Renal failures, congenital platelet disorders, Haemophilia • Specific Immunoglobuliins: passive immunization for Hepatitis B, Varicella, Tetanus • Fresh Blood: Massive transfusion, Bleeding Disorders Note: Fresh blood is especially ordered as certain components of blood deteriorate rapidly on storage and these are: Platelets, Factor V and VIII, Granulocytes

Exercise • List major functions of BTS • Advantages of using disposable plastic bags • List areas which blood bank should have • Criteria for accepting and rejecting blood donor • Blood transfusion committee in hospital and its role • Statutory requirements for BTS

Level of Blood Banks

Physical Facilities • LOCATION • Ideally on the ground floor. • Direct access from main entrance. • Signage system for easy visibility • Close to emergency department • Close proximity with/accessibility to hospital’s clinical service departments

Physical Facilities • Physical facilities and space of a Blood Bank can be grouped under the following areas; Donor Recruitment Office Bleeding Complex Therapeutic Area Laboratories Administration Area Teaching and Training Facility

The Path of the Donor Entrance Exit Waiting Room Donor Records Waiting Room Donor Laboratory Medical Examination Resting Room Blood Collection Donor Cafeteria

The Path of the Blood Blood Collection Distribution Refrigeration and Freezing Preparation of blood components Plasma Fractionation Path of Blood Components Path of Whole Blood Path of Plasma and Plasma Fractions

The Path of the Blood Samples Blood Grouping Blood Collection Labeling Testing for transmissible diseases Discarding after agreed period Results Blood Samples Path of Plasma and Plasma Fractions

Path of Materials Source of Supply Central Store Non Sterile Sterile Waste Department for use Cleaning Sterilization Department for use Waste

Designing a Blood Transfusion Centre • Building must be designed so that closed working areas (e.g. aseptic rooms) are not exposed to strong sunshine. • Climatic conditions to be considered, like, if wind carries dust ventilation by filtered air may be required • Donor, blood and outpatients shoud follow separate paths • Stand by generator

Designing a Blood Transfusion Centre • If a transfusion centre is not located within a hospital, the following supporting facilities must be needed; • Sterilizing Room • Laundry • Garage • Store Rooms • Changing room • Canteen for the staff of the centre • Workshop for maintenance of building and equipment • Suggested that a separate room be available for sterilizing equipment and stills

Designing a Blood Transfusion Centre • District level Transfusion Centre • A district centre with 50 donors per day needs floor space of 120 m sq • Regional Level Transfusion Centre • If daily bleedings number is 200, donor department floor space should be 300 m sq. • This assumes that more than half of the total donations taken by mobile teams • National Level transfusion Centre • Approx. 900 sq m

Physical Facilities • Donor Recruitment Office • Most vital activity for any blood bank. • Recruiting voluntary donors requires spread of public awareness through mass media or community approach. • It should have following facilities; • Donor Organizer’s space • Space for clerical staff • Space for type writer/ printer/ fax machine/ photocopier machine • Telephone with intercom facility • Computer for database management for recording and retrieval of data • Facility for printing and publicity material.

Physical Facilities • Bleeding Complex • It should be close to the front entrance, to ensure easy visibility, it will consist of following rooms; • Reception Room • Examination Room • Bleeding Room and Aphaeresis Room • Rest Room • Kitchen / Pantry • Daycare Room/ Treatment Room

Physical Facilities • Therapeutic Area • Consists of the facilities required for blood transfusion of those patients who require frequent transfusion of blood or blood components like patients of thalessemia and hemophilia.

Physical Facilities • Laboratory • Minimum movement of the persons in the corridor of the laboratory • Minimum access to the outsiders • The processing, typing and cross matching of blood is performed in this area

Physical Facilities Laboratory • The laboratories of the blood banks are of following types • Laboratory for processing donor’s blood • Blood component laboratory • Basic Work • Fresh Frozen Plasma • Cryoprecipitate • Platelets • Packed RBCs • Leukocytes poor RBCs • Relevant Coagulation Work

Physical Facilities Laboratory • Advance Work • Freeze dried and heated coagulation factors • Plasma Fraction • Donors Serological laboratory • ABO and Rh Grouping • Antibody Screening • Labeling Donor’s Blood • Storing of tested blood

Physical Facilities Laboratory • Infectious Diseases Laboratory The laboratory will have provision for testing of: • HIV • Malaria Parasite • Syphilis • HBV • Hepatitis C Virus • Special Laboratory The laboratory will do platelet and granulocytes serology.

Physical Facilities • Laboratory • Patient’s Serological Laboratory The laboratory will do following functions: • ABO and Rh Grouping • Antibody Screening • Cross matching of blood • Antenatal work up

Physical Facilities • Administrative Area • Consultant’s Chambers • Departmental office • Administrative and Clerical Office Rooms • Staff’s Common Room • Store Room • Wash Room and Toilet • Housekeeping Room • PRO’s Room • Medico Social Worker Room • Voluntary Counseling and Testing Center (VCTC)

Physical Facilities • Teaching and training Facilities • If the blood bank is a part of teaching/ training institution it will participate in teaching and training program. • In some of the hospitals blood bank is the part of Transfusion Medicine • It will have facilities of; • Conference Room • Demonstration Room • Departmental Library • Reading Room

Other Physical Facilities • Water Supply: It should be pyrogen free water • Electricity Supply: round the clock, uninterrupted to maintain cold storage temperature. • Sewage Disposal System: Effluent Treatment Plant • Storage System: separate facility for blood and blood components • Steam: for cleaning of glassware, equipments and sterilizers • Supply of Distilled Water: Especially deionized, for blood transfusion center • High Pressure Air Vacuum • Intercom System • Mobile Van for conducting blood donation camps as community programs

Staffing

EQUIPMENTS • Can be grouped as following: • Equipments for Routine Work • Refrigerator – for maintaining temperature to 1-4 degree with audio-visual alarm, temperature display, temperature recording, 24 hr power supply. Minimum number of refrigerator should be 3 • For untested blood -1 • For tested blood – 1 • Tested and Cross matched blood – 1 • Centrifuge table top • Water bath • Incubators • Hot Air Oven • Binocular Microscope

EQUIPMENTS • Weighing Scale for blood bags • Domestic Refrigerator • Ph Meter • VDRL Agitator • Weighing Machine for donors • Distillation Plant • Analytical Balance

T ransfusion Services