Blood Banking

[[p.1]]
Blood Banking
Dr. Bernard Fantus is the person to conceive the term "Blood Bank" and he opened first blood bank at
Cook Country Hospital, Chicago, USA, on 15.3.1937. Staff included Dr. Elizabeth Schirmer and Mr.
e.l. Mattas, With the advent in science and technology the Blood Banking which involves deposit,
saving and withdrawal like other banking system.developed into a established bioeconomical system to
economise the scarce resource blood for useful application to serve the needs of patient. Brieflythe
service can thus be divided in two namely Banking and transfusion. The banking part deals with deposit,
saving and withdrawal and the transfusion part deals with economic use of blood and blood products by
scientifically selecting the appropriate unit of bloodthat does not harm the patient. The complete operation
thus involves integration ofthe two subsystems, administrative and technological skill for smooth running.
And therefore, a rudimentary knowledge of the principles involved will help technologist to'appreciate
some of the administrative problems that may interfere with effective delivery of the products. In blood
banking the product delivered are consumable products (Blood) used for therapeutic application in
patient and some investigative report. It is unlike the other laboratory where products delivered are
mainly the reports, used as tools for supporting or planning the treatment. Proper knowledge of
administration is an essential partof blood banking sciences for smooth operation to achieve objectives
and goals.
3.1 ORGANISAnON, PLANNING AND MANAGEMENT
Organisation can bestated as a structure while planning is the function pervading all levels oforganisation
and management is the functional process of achieving the goal. Blood bank too is an organisation or
system and for smooth operation of this proper planning and management is necessary. An outline of
these three facets of administration in connection with blood banking is described below. For any
organisation there must be some clear cut function through which it can achieve its goal. In blood bank
main functions are :
1. To collect blood and produce blood product: industrial.
2. To store the blood and blood product and issue the blood and blood product: banking.
3. Reporting on certain test procedure : investigative.
4.
Clinical consultancy as and when requested: consultative.
5. Bleeding of polycythemia cases and transfusion in thallasemics : therapeutic.
27

[[p.2]]
28
Blood Banking and Transfusion
Objective, target and goal
For any organisation there must be clear cut objective or goal to be achieved. Objective is the plannec
end point of all activity either achieved or not achieved whereas target are discrete activity concemec
with degree of achievement and goal is the ultimate desired state. The objectives and resources art
directed to achieve the goal which is not constrained with time.
In blood banking objective is to maintain aconstant (twenty four hours) supply of quality blood an<
bloodproducts consumable by human being for improvement/cure of the patient Degree of achievemen
in terms of targeted supply may differ from organisation to organisation and depends on how smooth i:
the administrative and technical operation and coordination.
From the above mentioned statement on function and objectives of a blood bank it can thus bewe]
perceived that modus operandi of administration of blood bank ought to be different from any othe:
organisation viz. laboratory or clinical or para clinical "Organisation is the systemic bringing together 0:
interdependent parts to form a unified whole through which authority, coordination and control may be
exercised toachievea givenpurpose" - Dimock,Toensureinterdependency,coordinationandcooperatior
the following is considered :
ta) Hierarchy or vertical dimension and in any organisation it should be like pyramid broad at base
and tapering at top.
(b) Span of control: An effective control is better achieved with shorter span of control.
(c) Command: Unified command though better but has been modified now-a-days to infuse more
senseof coordination andcooperationbut then nobody should be allowed tobypass the authority
(d) Centralisation and decentralisation respectively means concentration of authority and dispersal
of authority to individual unit.
(e) Delegation means transfer of function or power to the subordinate by superior.
(f) Line and staff: Line functionary are those who work for direct achievement of objective. Staff
are advisorial functionary.
In the setup shown inTable3.1, which is an independentset up (presentday bloodbank organisation)
consultant or director is the decision making faculty who formulates the policy in consultation with
Head of Institution or by himself. In medium set up the Assistant Professor similarly works where he
formulates policyinconsultationwithHeadof Institute.In smallerset up it is thepathologistliransfusionist
similarly works and the formulates policy in consultation with Head of Institution. Line functionary are
thus consultant, Assistant Professor, Pathologistffransfusionist, Junior Doctors, Technical Supervisor,
Technical Assistant, Technician Lab Assistant, Lab Attendant
Staff functionary are nurse, social worker, donor organiser and other ministerial staffs.
In the set up which is attached to department of pathology the decision making faculty is the
consultant pathology and senior doctor in blood·bank work as middle level management faculty who
works under guidance from decisions making faculty.
Planning can be defined as a conscious effort through a predetermined course of action to achieve
the goal by process of adjusting the characteristic of the system and to the environment that may be
static or variable.
Main purpose of planningis to achieve the set objective priority-wise by accomplishing the function
in an existing environment with the kind of resource available.
Environment-Sociopolitical, economic
Resource-material (equipment etc.) and manpower

[[p.3]]
Blood Banking
29
Table 3.1. Standard organisational structure of blood bank working for 24 hours for 7 days
5000 donors unit
10..000 donors unit
20,000 donors unit
processed
per year
processed per year
processed per year
Bleeding room
1. Junior Doctors
2
4
4
2. Nurses
2
3
4
3. Social Worker
1 .
1
2
4. Attendants
I
1
2
Apharesis room
1. Nurse
-
-
2
2 Attendant
- .
-
1
Laboratory
1. Technical Supervisor
-
1
4
2. Technical Assistant
2
4
8
3. Technician
5+3 (for shift works)
11
13
4. Lab. Assistant
1
2
4
5. Lab. Attendant-
2+1 (for shift work)
4
4
Donor organiser
Associated clerical staff
-
1
2
Service staffiClericalstafT
1. Clerkffypist part time
1
1
1
2 Store keeper part time
1
1
1
3. Cleaner/Sweeper
1
1
2
Medical doctor
1. Consultant/Professor
-
-
1
2. Assistant Professor
-
1
1
3. Lecturer
1 (Pathologistltransfusionist)
-
3
Workflow: Blood bank should be centrally located, easily accessible particularly from OPO, operation
theatre and emergency services and intensive therapy unit. And again Reception and registration. Bleeding
room, routine working laboratory, cold storage etc. must be located in close vicinity so that there is
minimal interference in the cold chain system, minimal stress to the staff and adequate supervision is
possible. The criterion of environment and resources are beyond the control of planner but the other
two are within the ambit of planner, while planning with the objectives in mind one has to find out an
adaptible and easily accessible means. And a mix of innovative andtransactive planning applied to the
basic -principles of planning may suit the purpose. Basic principles of planning are :
(a) "Form follows function"
(b) Maximum flexibility and expansibility are paramount
(c ) Simple extemaland internal traffic pattern
(d) Adopt labour saving device to reduce operational cost
(e) In building any new facility the old must adjust to new

[[p.4]]
30
Blood Banking and Transfusion
In innovative planning one has to adopt to any change and in this process may have to take into
consideration thecauseeffectrelationship andrestructure therelationshipwith environment.In transactive
planning participation is the central theme. Involve as many people as possible in planning, e.g. in
maintenance of stock of blood and blood products a constant supply is needed which can be further
improved by arrangingthe donationprogrammeand productionactivity through participationof public,
non-governmental organisation and workers and vice versa.
"Management is the process by which managers create, direct, maintain and operate purposive
organisation through systemic, coordinated, cooperative human effort" -
Dalton. Marfarland.
Properlymanagedorganisationthroughproperimplementationof planningcan serve the purposeof
achievingthe goal.
I
Responsibility
Fiscalmanagement
!
Budgeting
I
I
Zero
Manual Verbal
Dataprocessing &
telecommunication
~
EXECUTIVE~
~'/1
~
~
MIS
MIS~
M
lal and
I~
~
ateria an
personna
<:::
communication
"
Manage,nent
(MIS)
;>
+
1. Planning
2. Organising
3. Staffing
Co-ordination
4. Directing<Control
Fig. 3.1.
From Fig. 3.1, it can thus be understood that how an executive at top manages the function, of
course through communication which is vital for execution of management function. Material and
personnel management is thus executed. through proper implementation of planning, organising the
activity by proper staffingand directingthrough co-ordinationand control. Fiscal managementthrough
budgeting (estimatingtherequirements toperformtheactivitiesduringa particularperiod).Responsibility
budgeting follows the philosophyof placing the accountabilityat the lowest level of management.
l , Planned and actual expenses are to becharged to the lowest level of organisationfrom which
they are incurred.
2. No expense item is to be charged to a department unless department can exercise control of
that expense item.
3. All departmentsincludedin thebudgetmustbeheadedby someone whocan beheldresponsible
for the costs of department.
4. Every item of expense can be controlledby some one in total organisation.
S. The departmental head must participate in budget formulation and agree that the planned
expenditureof his or her organisationor unit is realistic.
In contrast zero budgeting is founded on the assumption that no'base budget is carried forward to
next year and compels denovo examinationof each and every activity,its justification etc.
Budgeting helps managementby providingclear definitionof the objectivesthrough economic and
planned expenditureof financial resources.

[[p.5]]
Blood Banking
31
As has been stated earlier that communication is vital link in the management. Communication can
be intralaboratory, extralaboratory or with the users for which effective MIS (Management Information
System) is required (Fig. 3.2). MIS can be of three types manual, verbal, data processing and
telecommunication -
computers and selection of aIJY particular programme depends on circumstances
and suitability to the organisational need. Executive accomplishes the management function through to
and fro flow of information. between laboratory, himself and user. Thus the blood bank MIS has to be
interlinked with the hospital and in case of independent blood bank it is directly linked with Hospital
information service otherwise linkage is through laboratory to which it is attached.
~ExecUtiVe
Intralaboratory
~
Intrasectional
~L.l.S----...
Blood
~
Bank M.i.S.
H.I.S.
BloodBankManagement
Information system
Independent BloodBankHospital
L--
.
---J
Fig. 3.2.
Experience has shown that blood bank definitely has an edge over the other system.. And as such in
all the major hospital blood bank is working as an independent unit now-a-days. Thus a result (output)
oriented administration of blood bank is possible through appropriate planning and management of an
organisation suitably equipped with communication and supported by proper infrastructure.
3•.2 DESlGN, ,SET UP
In view of the functions of diversified nature and round-o-clock essential service for patient care, blood
bank has to be located in a central place easily accessible preferably in a ground floor and should be well
communicated to all department and existing services of t* hospital. To have separate entry and exit
with wide corridors and waiting space so that there is less traffic congestion, laboratory and other
rooms must bespacious enough with minimal public entry sothatthere is no interference in the work of
technician or doctors. This atmosphere in work is required to have a rapid turn around time and standard
quality work. It should have such design that the bleeding room, cold storage for blood and blood
product viz. deep freezers etc. storage for antisera blood bag, routine working laboratory and component
separation room areplaced in closed vicinity. This is to ensure minimal interference in cold chain system
by giving less outside or atmospheric exposure to the blood and blood products during shifting from one
room to the other. Any breakage or tripping in the system, e.g. power failure etc. must be immediately
corrected and till such time emergency or alternative power system is made to work. Blood bank
refrigerator, walk in cooler, deep freezer, all must be fitted with audio visual alarm system to indicate the
existing temperature at which the machine is working. What has been described .is fundamental to any
blood bank Designing, set up standard is described below along with a drawing which takes into
consideration the work flow, functional flow and tum around time. The drawing (Fig. 3.3) is combined
drawing and have two wings, one for smaller set up that is 'A' wing and another is a bigger set up of
blood bank with R&D facility. Design can be adopted with little alteration here and there. suit the
individual requirement.
.

[[p.6]]
32
Blood Banking and Transfusion
CombinedDesign (AandB)A : BloodBankonly,A & B : BloodBankwithResearch Facility
CombinedDesign(A and B) A--BloodBankonly a&B--Blood Bank with Research Facility
i
22
10
1 i
f
0)
c
9
8
4
§
18 1~1~
15
<t
C
20
19
t
C
L-J
W i
w W
~A
W
1A
0)
C
c
~
7A
6A
SA
4A
ent
Adminis
Block
Supportive
Services
Admission
Enquiry
Blood
I
Bank
Indoor
Complex
OPOComplex
Emergency
leu
ICCU
Gynae
Burns
OT
Complex
Outline of GeneralHospital
ShowingLocationof Blood
Bank in Ground Floor
W :Waiting,C:Corridor, X :Airconditioner, ++:Window, ....:Coldchain...,Toilet,# : BloodBankRefrigerator
(1)Record;(1A)Thalasemic Opd treatment; (2)Office;(2A)Haemoglobinopathy Lab;(3)Store;(3A)G6PD;(4) Enquiry
Reception withwindowfor donorand recipient; (4A)Apharesis; (5) Doctorsduty room; (SA)Cell separator; (6) Donor
waiting;(6A)CentralComputer; (7)DonorScreening; (7A)HLA,Complement; (8)Maindonation room; (8A)Director; (9)
Emergencydonation; (9a) Steno;(10) MSWand Nurse;(10A) Office;(11) Dorior recovery; (11A)GeneralStore; (12)
BTO; (12A) Steno;("128) Staff facility; (13) Reagent, chemical store;(13A) Library;(14) Walk-in-cooler; (14A) Senior
Doctor; (148) Deputy Director; (15)Spacetordeepfridger; (15A)Steno; (16)Routine lab;(16A)Seminar/Classroom; (17)
Immunohaematology lab;(17A)Trainee doctorroom; (18)Biochemical lab;(18A) Animal room; (19)Component Separation;
(19A) Wash room;(20)· Labfor HIV, HBSAG, Syphillis, MalariaorotherTID; (21) Electriccontrolroom;(22) Hot area
(Autoclave, incinerator) (Notas perscale)
Fig. 3.3.
An ideal systematic design of blood bank and transfusion service department has to take into
consideration the three described criteria work flow, functional flow and turn around time. This is
required for supply of quality product uninterruptedly and as quick as possible.
Functional flow
Reception : Registration
) ~ Patient care service (Receiving requisition etc.)
-+ Donor service (Receiving the donors)
(a) Patient.care service: Receiving requisition and other office formality -+ Pre-transfusiontesting
of sample -+ Issue of cross matched blood or blood product tothe patient.
(b) Donor service -+ Reception .and recruitment ~
Screening ~
Declaringfitness of donor ~
Collection of blood from fit donors ~ Grouping of donor blood -+ Testsfor VDRL, HIV, MP,
Hey and HbSAg ~ Storage.
Donor recovery and motivation is the other part of donor service.

[[p.7]]
Blood Banking
33
(c) Documentation and recordingetc. may be manualorcomputerised as deemed necessary by the
administration. Apart from the major function describedcertainother functions are carried OUI
in bloodbank viz. investigative and therapeutic.
Investigative : leT, DCT, outdoor bloodgrouping, HLA.
Therapeutic:Bleeding inpolycythemiacasesandoutdoortransfusion inestablishedthalassemics.
The work flow pattern has briefly been described earlier while designing for a blood bank anc
transfusion service department follow some minimum standard so that quality and service is not
compromised. Standard area according to number of donor population is described below (Table 3.2).
Table 3.2. Standard for space for blood banks (Building area in sq. meters) (For yearly blood collection)
500 blood unit
10,000 blood unit
20,000 blood unit
Yearly
Yearly
Yearly
1. Reception room
2 Bleeding room
3. Refreshment room
4. Kitchen pantry
5. Apharesis area
Laboratory area
t. Laboratory for routine work and antinatal work
2. Laboratory for special RBC Serology,
quality control
.3. Laboratory for specialised work platelets,
.
HLA serology
4. Issue counter and contingency counter
5. Hepatitis, AIDS, VORL etc.
6. Wash basin, distillation plant to
7. Component basic
8. Component-advanced and freezer drying etc.
9. Room for arrivals
General areas
1. Doctor's office
2. Donor recruitment/Social worker andassociated
clerical staff
3. Blood Bank Officer
4. Stores
5. Technician common rOOlD
6. Toilets
7. Trainee doctors room
20
40
15
5
25
15
20
20
15
25
15
20
15
5x2
25
55
23
5
40
25
18
20
20
25
20
15x2
30
15
25
20
5x2
40
ioo
30
10
40
50
50
50
20
30
30
40
50~
30
15x4
50
25
35
25
5x2
25
3.3 DOCUMENTATION AND RECORD
This is the most important part of the blood bank administration as the proper documentation and record
keeping will help anybody to trace the whole history pertainingto any unit of blood bag. Moreover!

[[p.8]]
34
Blood Banking and Transfusion
alJ these records may becomemedico-legaJ evidence in case of any mishap connected to transfusion. So
the documentation and record keeping is vital to blood bank administration. These records are to be
maintained for five years and then destroyed after obtaining the administrative approval.
Record -
Donor
1. Donor Registration card for individual donor.
2. Donor Register.
3. Negative and rare blood group register, subgroup may also be entered in the same register.
4. Donor Requisition form.
5. Voluntary donor register.
6. Record of blood and blood product from outside source, which must be non-commercial like
Red Cross or any other government approved hospital.
7. Blood Component Record Register.
8. OPD register (entry of all OPD cases and their report).
Patient
1. Reception and Registration record with time mentioned.
2. Requisition form from. the ward.
3. Pretransfusion test report of patient's blood.
4. Cross matching report.
"5. Issue register and specimen register with report.
6. Transfusion reaction register.
Other Register
1. Quality control register.
2. Special register (Combined) HIV and HbSAg positiveperson and HC\z
3. Monthly report indicating yearly consumption of blood and blood products and performance
on daily basis.
4. Annual report indicating yearly consumption of blood and blood products and performance
monthwise or any other alteration, addition or achievement significant to blood bank.
5. General stock register :
(a) Expendible items
(b) Non-expendible items
(c) Stationary.
6. Temperature record register : If thermograph arrangement is not available with individual
refrigerator then a register that keeps a record of individual refrigerator for 24 hours on hourly
basis is to be maintained to indicate. the performance of machines.
7. Work performance register by technician that indicates the work done by technician on duty,
balance in stock while handling over to next technician and the amount of blood or products
issued during his duty hour, number of donations received. Status of individual units of blood
being handed over i.e. units under observations for HIV, HCV, STS, HbSAg, unit recommended

[[p.9]]
Blood Banking
35
for repeat test, unit declared positive, units which are tested negative into above tests and safe
for transfusion purpose and amount of work pending for next technician.
N.B. : Important formats in daily use or followed in Blood Bank is given at appendix.
3.4 BLOOD DONOR
Recruitment of donor
It is done at the reception counter for donors and the particulars for acceptance of donors to be verified
such as name, address, sex, identification mark in case of both replacement and voluntary donors. If
particulars as mentioned in the donor proforma are correct, donors are accepted for screening purpose.
Donors can be broadly subdivided in three o/pes : (i) Replacement.Iii) Voluntary, and (iii) Professional.
(i) Replacement donors are usually relatives of patients who donates blood as replacement against
the demand made for a particular patient. So these are known as non-remunerative directed
donations. As such replaced in patients against whom the donation is directed and for this all the
donors are issued with a card stating that the donation of the unit of blood is done on this date
bearing serial number say 'X' for particular patient named 'Y' admitted in ward having the bed
number say 'Z'. This statement is signed by blood bank doctor who has collected the blood. At
the time of requirement the ward doctor sends a requisition form and attaches the donor card
for replacement to be made in case of particular patient by an appropriate unit of blood suitable
for the patient and this unit must be cleared or declared negative for HIV, HBSAg. STS and MP
and HeV within the period of expiry and not haemolysed or contaminated. The dOD9r card
remains valid for one year after the date ofcollection. In case, ifdonor desired that the particular
unit which has not been used in patients for whom donation has been made be directed to some
other patient, a specific written instruction in this regard can be issued to blood bank by the
concerned donor.
(ii) Voluntary donors are those who donates blood as a matter of principle sometimes periodically
i.e. at a period of permissible interval which should not be less than three months in any case.
This period can be a regular interval or irregular viz. once in a year, twice in a year regularly,
every year or no fixed period for such donation but of course more than three months, These
donations are not directed and non-remunerative and the cards issued can be used for any
patient who does not have replacement donors.
(iii) Professional donors are the paid donors who sells blood in lieu ofmoney. This types of donation
could be directed when purchased by patients party and non-directed when purchased by blood
bank. This type of donation are discouraged now-a-days by all government hospital blood bank.
Fourth type of donation is autologus donation and is described later at appropriate chapter.
After observing the formality in reception counter the prospective donor is sent in for screening
purpose. During screening a qualified doctor puts him some questionnaire and examine the donor both
general, physical and laboratory examination.
Questionnaire are put to the prospectiv~ donor to ascertain his status as donor replacement, professional
etc. If during cross questioning and other ancillary examination viz. multiple prick mark in antecubital
fossa, in some cases veins also get thickened due to repeat needle prick it can be established that donor
is a professional donor then it is better to reject the donor. If the attending doctor is satisfied regarding
the status of the donor then he proceeds for general examination and physical examination of the patient
and also haemoglobin examination by either CuS04, Sahli's haemoglobin estimation or other method.
And if everything isfound within normal and permissible limit then only the donor is'taken into the main
bleeding room for donation of blood.

[[p.10]]
Fig. 3.4. Palm showing papulo-squamous
rash syphilis afflicted donor.
36
Blood Banking and Transfusion
Criteria for selection of a donor
I. Age : 18 to 60 years.
2. Weight and height: For donors 5 ft. tall and above 45 kg (99 lbs) can donate blood. For every
inch increase in height the minimum necessary weight increased by I kg. Donors of and above
55 kg of any height can safely donate blood.
3. Frequencyofdonation: The interval between the date of last donation and the date of present
donation should not be less then three months in any case.
4. Pulse: 50 to loo/min regular.
5. Temperature: 98 to 98.6°F (afebrile).
6. Haemoglobin level: 12.5 gm dl.
7. Bloodpressure:
Systolic -
100 to 200 mm of Hg
Diastolic -
50 to 100 mm of Hg
While examining the patient we must take history of donor particularly the family history, personal
history, history of any disease he has suffered from or suffering, history of any previous transfusion,
history of any vaccination of drugs etc. to declare the donor fit. Family history, marital status, family
member in the household, try to elicit history ofany familial disease viz. haemophilia, thalasemia, epilepsy
allergy, asthma etc. in such cases donors are examined for specific disease and if found positive in
donor too, the donors are not accepted.
Personal history: Occupation (may sometimes lead physician to detect any disease, donor might be
suffering from, viz. leukaemia, in certain profession Anthrax etc., habit of drinking or addiction to any
particular drug viz. opium etc. or any extramarital
relationship or habit of visiting redlight areas etc. may
give clue to the attending physician (Fig. 3.4).
History of transfusion -
whether the donor
himself has received any transfusion of blood or blood
product during preceeding six months and if so donors
are not accepted.
History of jaundice fever has to be· particularly
asked for, to negate hepatitis and malaria.
In
case of females
history of lactation,
amenorrhoea and pregnancy has to be asked for. Female
donors made temporarily unfit in case of lactation and
menstruation. The donor must not be empty stomach
and he must take some food at least one to one and
half hour before donation.
History of vaccination also has to be taken :
(a) Donors who have received killed vaccine, e.g.,
cholera, typhoid, diphtheria, influenza, tetanus,
whooping cough should donate one week after
vaccination.
(b) Donors who have received live vaccines, e.g.,
BeG, smallpox, yellow fever, rabies, must not
donate for at least 3 weeks after vaccination.

[[p.11]]
Blood Banking
37
(c) Those who has received antisera viz., ATS, gas gangrene sera or antidiphtheric sera should not
donate at least for 4 weeks.
Drug therapy
Avoid donations from donors receiving anticonvulsant, anticoagulant, corticosteroid, hypotensive drug,
analgesic, antipyretic, particular attention for those containing aspirin, antihistaminic etc. In case the
donor is meant for blood from which platelets are to be processed reject any donor with history of
ingesting aspirin during previous 72 hours or those who are habitual taker of aspirin or drugs containing
aspirin. History of any other disease the donor is suffering from and donor is accordingly accepted or
rejected. A summary of diseases are given in Table 3.3.
.
Special precautions to be taken and preferably do not collect any donation from patient suffering
from cancer, bleeding disorder, blood cancer or donor exhibiting any immunodeficiency syndrome.
After all the formalities are observed and the attending doctor is satisfied and found the donor
physical and other criterias as described in Table 3.3 arewithin normal limit or nothing against detected
the donor is declared fit.
Next the donor is taken to the donation room or bleeding room, the room must be spacious enough
to accommodate 5/6 or ten donors (area for bleeding room has already been given); fitted with
airconditioner, ceiling fan, sufficient and adequate light and emergency drugs, oxygen cylinder etc.,
refrigerator for immediate storage ofblood after collection. Comfortable examination table, B, P instrument
and tourniquet, spirit swab. Bleeding room be checked up periodically by hospital infection committee
and swab culture obtained from different places to detect any bacterial contamination, if gross
contaminations is reported proper care for disinfection is taken.
Donor walks barefooted in the room and he is made to lie down on examination table in supine
position he is made to feel comfortable on the bed and doctor allays his anxiety or fear of donation if he
has any.
In some collection centre, donor chairs (manufactured by Baxter) are used where donors are made
to seat for bleeding.
Site selection and body position
The selection of site for bleeding, technique of blood withdrawal and position of donor is of paramount
importance for both the donor and phlebotomist.
Position of the donor/patient while withdrawal or administration of blood is important because
procedure takes quite a long time so patient/donor must be placed in a comfortable position that doesnot
interfere with the process rather helps for smooth operation and continuation ofthe process. Phlebotomist
should also find it smooth for operation.
By experience it was found that supine position is the best position for both the donor/patient and
the Phlebotomist. Further the gravitational effect is more pronounced when the body is in erect posture.
Supine position when both limbs are at rest, veins/artery are easily accessible to the operator and
wrapping round the cuff of B.P. instrument is easier. For all this facility available, both the upper limbs
are usually selected for puncture of veins either to withdraw/administer the blood.
Veins are mainly preferred because :.
1. They are placed superficially.
2.
They have an unidirectional flow (Fig. 2.1, Chapter 2) of blood directing the blood towards the
heart.

[[p.12]]
.38
Blood Banking and Transfusion
Table 3.3. Medical ailment
1. (Severe) Allergy
2. (Severe) Asthma
3. Bronchiectasis
4. Bronchitis
5-.Cardiovascular disorder
6. Chickenpox
7. Coronary artery disease
8. Diabetics
9. Diphtheria
10. Dysentery
11. Eczema
12. Embolism
13. Emphysema
14. Epilepsy
15. Gout
16. Gonorrhoea
17. Infective Hepatitis (A)
18. Hepatitis (B)
19. Hyperthyroidism
20. Hypothyroidism
21. Influenza
22. Jaundice
23. M~laria
24. Measles
25. Mumps
26. Pregnancy and abortion
27. Polycythemia veta
28. 'Psoriasis'
29. Syphilis
30. Tetanus
31. Tuberculosis
32. Typhoid
Surgery
1. Tooth extraction
2. Appendicectomy
3. ENT operation
4. Herniorraphy
5. Major operations
6. Gastrectomy
7. Cancer surgery
8. Fractures (Major)
9. Minor/Trivial fracture
10. Minor operations
Permanently unfit
Permanently unfit
Permanently unfit
Fit after recovery
Permanently unfit
Fit 3 weeks after recovery
Refer to medical specialist for opinion
Fit if well controlled
Fit 3 months after recovery
Fit after recovery
Fit if not on drugs
Permanently unfit
Permanently unfit
Permanently unfit
Fit during remission
Fit 2 months after recovery
Fit 4 years after recovery
Permanently unfit
Permanently unfit
Permanently unfit
Fit after recovery
Fit 6 months after recovery
Fit 6 months after recovery
Fit 3 months after recove~
Fit 3 months after recovery
Fit 3 months after recovery
Permanently unfit
Fit if not on drugs
Fit if fully and properly treated
Fit 6 months after recovery
Fit 2 years after recovery
Fit 6 months after recovery
Fit after seven days
Fit after six weeks
Fit after six weeks
Fit after three months
Fit after six months
Permanently unfit
Permanently unfit
Fit after six months
Fit after cure or union of bones
Fit after six weeks

[[p.13]]
Blood Banking
39
3. Since blood moves from point of high pressure to lower pressure, pressure gradient gradually
lowers from aorta to bigger artery and in medium sized artery, it is about 120 mm in capillary,
-20 mm less in the venules, lesser in veins and almost negative in larger veins. This negative
pressure in veins and the negative pressure in thoracic cavity during inhalation helps return of
venous blood to heart.
4. Stored blood usually contains less oxygen so the blood administered in the veins passes through
lungs and gets rejuvenated through oxygenation in lungs.
5. While entering heart it gets mixed with lymph which along with other things carries fat and
other substances viz. lymphocytes etc.
6. Very little chance of backward flow due to valvular arrangement in veins.
7. Venous blood is the returning blood that is going back to heart after the metabolic"exchange has
taken place in tissues and cells thus it is free from liability of feeding any important organ.
8. The withdrawal of blood from vein will not disturb the pressure gradient required for onward
flow of blood.
9. Veins are less resilient than artery. Arteries are more resilient and increased pressure in artery
may make it more difficult to stop bleeding and arterial puncture may interfere with normal
blood flow if spasm occurs.
. 10. Veins are placed superficially so any haematoma formation etc. can be easily" seen even by
"donor/patient and necessary precautions can be taken immediately but reverse is observed in
artery - local discomfort viz. pain of throbbing nature, cramps etc."is more pronounced in
artery and this may have demoralising effect on donor patient.
Commonly used site for venepuncture which fulfills most of the criterions described, are the veins
in cubital fossa of both the upper limb.
-
1. Handling and manipulation ofboth upper limb without disturbing the patient in a supine position
(whether he is conscious or unconscious) is possible.
2. Blood pressure cuff can be easily wrapped around the upper arm.
.3. Any haematoma formation during procedure is easily noticeable by patient/donor and he or she
can draw the attention of doctor.
4. In anticubital fossa veins are numerous, adjacently placed, superficially·placed above bicipital
aponeurosis which covers almost all the important structure in the cubital fossa So chance of
damage to deeper structures without resistance to needle from bicipital aponeurosis is rare.
5. Veins are tightly bound to superficial fascia so less chance of mobility or slipping of vein after
it is fixed or anchored prior to puncture.
6. Veins are nearer to heart and pressure gradient is approximately 5 mm or less which is helpful
for both withdrawal and administration.
7. Exercise of upper limb is possible while the withdrawal procedure is in operation, slow rhythmic
contraction and relaxation of the muscles enhances the venous return of blood.
8. Simultaneous record of pulse is also possible in the upper limb.
9. Alternative sites are easily available.
On selection of the site, the part isprepared first by application of iodine followed by rectified spirit,
three applications by each antiseptic with cotton swab held with a swab holder and is moved from
centre to outwards always and do not bring back the same swab to centre again. If the veins are not
prominent then they are made prominent by applying local pressure or by exercise of the upper limb,
Once they are prominent they are anchored by phlebotomist hand. And now raise the blood pressure to

[[p.14]]
40
Blood Banking and Transfusion
A. Packing vein in cubital fossa
C. Single blood bag with pilot tube
B. Application of haemoclip after
donation is over
Fig. 3.5. Different stages in blood
collection.
a level just below the diastolic pressure or little above (varies in individual cases) so as to compress the
venous blood flow without altering the arterial blood flow; if donor complains of some discomfort viz.
tingling etc. then pressure has to be reduced. Once the pressure is fixed donor is asked to hold the catch
tightly, this makes veins more prominent. Now proceed for venepuncture, local anaesthesia though
practised earlier are avoided now-a-days and direct venepuncture is preferred more. Blood bag or bottle
respectively with CPD anticoagulant or ACD anticoagulent is made ready number on bag and donor card
cross checked, clarity of anticoagulent solution is checked, also the bag is.checked for leakage. The
bleeding set which is an integral part of the blood bag contains a needle (16-18 g) which is kept sterile
under cover of a protector. Needle should be ultrathin wall with small outer diameter and large inner
diameter for maximum t1ow, the needle tip has bevelled end
for smooth operation and minimise penetration resistance. The
collection tube of bleeding set should not be less than 61 em.
Make a loose loop in the tube about 10 ern from the distal end
of the needle and make another loop at a little distance from
the tirst loop. Bag is hanged 60 em below the arm and it is
attached with special hook provided in weighing scale pointer
already fixed at zero mark of the scale. Now occlude the
collection tubes with hemoclip. The needle is uncovered by
twisting the protector seal, if the seal is found loose bag is not
to be used. Venepuncture (Fig. 3.5A) is done at selected site
which is already made sterile by iodine and spirit, while piercing
the vein the bevelled end faces up towards the operator so that
there is less resistance while piercing. Now observe for blood
flow in the tube and if satisfied hemoclip is loosened and blood
is allowed to flow, simultaneously donor is asked to tighten
and loosen his grip around the catch (usually gauzepad) the
pro-cedure is continued throughout collection. When blood
starts entering the bag a gentle and continuous agitation of bag
is necessary to allow thorough mixing of blood with
anticoagulant. One ml of blood approximately weighs about
1.05 gm so 350 ml of blood will weigh 367 gm. 10% ± is
allowed and when the scale indicates that the weight has
reached, discontinue the withdrawal of blood by closing valve
.between loop and needle. Pressure in BP instrument is released.
donor asked to stop exercise, the catch in hand is removed.
needle withdrawn gently by applying light pressure, put a swab
over venepuncture site, apply little pressure and ask the donor
to put the tingers of other hand over the swab while maintaining
light pressure, he rests supine in this posture for about ten
minutes. The bandaid is applied and the donor is taken to
refreshment room. After withdrawal of reedle, the bag is
detached from the weighing scale and the haemoclip/artery
forceps (Fig. 3.5B) is reapplied. The bag is now taken to
processing table and the artery forceps or haemoclip is loosened
and six to eight ml of blood is equally distributed in three
prenumbered pilot tubes, the numbers are same as that of bag.
These are the serum specimen used (Fig. 3.5C) for grouping.

[[p.15]]
Fig. 3.6. Weighing machine for blood
collection.
Blood Banking
41
Hlv, HbsAg and HCV,STS test.The knot distal to needle
is tightened needle is separated by cutting with tube
handsealer and cutter, another knot is now applied distal
to the previous knot and the content in this segment is
used for pretransfusion test This segments can also
be made and numbered with help of hand sealer for
easy identification. Keep the blood bag immediately into
the refrigerator of donor room at 4 to 6°C till transferred
to working lab for grouping and labelling etc. An unit
of blood as per Indian standard, one unit of blood
contains 350 ml content in a blood bag. 49 rnl CPDA
anticoagulant is provided in a blood bag for collection
of 350 ml of blood. This is called one unit of blood.
Precautions to be observed in donor room :
1. Venepuncture site must be free of any skin
lesion and necessary asceptic precautions are
to be observed before venepuncture.
2. If.the amount of blood to be collected is less than 350 ml, then proportionate reduction of
anticoagulant is to be done.
3. Any adverse reaction to be attended forthwith adverse donor reaction may manifest as :
(a) Syncope due to vasovagal syndrome which may exhibit as fall in BP, cold clammy skin,
sweating over forehead , rapid pulse -
Bleeding stopped immediately and donor made to
lie down with foot end of bed up and head end low.
(b) Sometimes donor may suffer from tetanic spasm of the muscle which may be due to
hyperventilation and loss of CO., due to deep breathing-bleeding stopped, donor is ased to
~xhaJe
in a closed paper bag and reinhale the air from the closed paper bag.
(c) Sometimes convulsion, nausea and vornitting may occur-Bleeding stopped, donor made
to lie with head on one side to prevent aspiration, well ventilated atmosphere is provided,
cloths are loosened.
(d) Haematoma may occur due to double puncture of veins-needle immediately withdrawn
from the vein and sterile cotton swab applied with light pressure over the vein and maintain
this pressure till oozing of blood stops, when no blood oozes even after milking band aid is
applied and donor advised to apply thrombophob ointment over the place if haematoma
still persists on next day. Bandaid is removed on next day. Donor may be given mild
analgesic for the night.
(e) Air embolism though does not occur very frequently but is a grave risk for the donor. It
exhibits as shortness of breath, shock, pallor etc. Place donor on left side with head down
immediately and transport donor under oxygen to medical emergency.
4. No outsider is allowed inside bleeding room viz. attendant of donor.
5. Donor consent though not mandatory but has to be obtained preferably after donor has been
explained properly and thoroughly regarding whole procedure and the risks involved. This
consent is for the safety of phlebotomist
The whole procedure of collection of blood as described above is known as gravity collection and
the process should not take more than five to seven minutes if the operation is smooth and flow is

[[p.16]]
42
Blood Banking and Transfusion
continuous. If procedure takes more than 8 minutes then the content of the bag is suitable for use as
whole blood but may not be suitable for component separation viz. platelet, FFP or cryoprecipitate.
The unit of blood thus collected has to be processed and it depends on how the unit will be utilised
viz. as whole blood or FFP or an,Y other component.
1. First step in processing is numbering, labelling.
2. Grouping ABO and Rh is done in working laboratory inunediately.
3. Serological investigations of serum for STS, HN, HbSAg and HCV.
4. Peripheral smear for malaria parasites.
All these particularly serial No. 3 and 4 is mandatory in India without which any unit of blood or
blood productis not given clearance. In USA two other tests are to be done in addition to above, they are
tests for CMV and HTLV. If any of the tests is found positive the concerned unit of bag is kept under
observation (for confirmation of the report) at 4°C± 2°C. If report is confrrmed as positive the unit is
discarded. Otherwise all the units of whole blood tested negative is stored at 4°C ± 2°C and cleared for
issue. STS reactive blood is issued after 72 hours preservation at 4°C ± 2°C.
If the components are to be prepared, it has certain additional criteria involved in processing which
are to be followed.
For FFP processing, testing must be completed within six hours and component separation started
within six hours of collection. Forcryoprecipitate same has to beobserved, and both are stored in deep
freezer. For platelet preparations blood bag has to be kept at room temperature (20 to 25°C) after
collection of blood. The donor has been taken to the refreshment room is greeted with smile and offered
light refreshment with warm hospitality. Here while the donor rests medical social worker takes over
and talks to the donor, while handing over the card it is explained to the donor the utility of blood he has
donated and the good work he has done, he is further explained that an unit of blood at an interval of 3
months between two successive donation will not cause any harm to his person or physiology. The
donor who has now been allayed of his fear after first donation can be considered a fertile soil and
properly.motivated he may proved to be useful in blood donation movement not only as regular donor
but also by inducing friends into the movement. With the passage of time and experience focus of
attention has now been shifted to community responsibility from individual responsibility and from
replacement to voluntary donation. In India we cannot meet our demand of blood even for our brothers.
We are having population of 860 million and 28% of whom are supposed to be in the age group of 20 to
40 years. With proper blood donation movement if we can motivate this group of people most of whom
are supposed to be healthy and tap even ]0% of this population after rejecting the unfit donors etc. and
pursuade them for regular and voluntary donation, we can easily meet our requirement.
So motivation plays an important part in blood donation movement and combined strategy ofindividual
and community responsibility along with replacement and voluntary donation, will definitely improve
our reserve of blood. A joint effort by blood bankers; MSW and non-governmental organisations in this
regard by meeting, seminars, media advertisement will definitely achieve good result.
All the donors attended after donation has to be given some instructions viz. drink more 'fluid and
not to stay hungry. Alcohol drinking to be aovoided .as far as practicable and if possible for the whole
day. Smoking avoided at least for half to one hour. If bleeding occurs from venepuncture site return to
the blood bank doctor. For haematorna precautions has already been stated earlier.
The bandaid to be removed next day. After giving these instnv-rions donors are thanked for the
donation and encouraged to return back again. Giving instruction to donor and bidding him good by with
smile are also part of motivation.

[[p.17]]
Blood Banking
43
Effects of blood donation on a healthy donor is transient in nature, volume is replaced within 48 to
72 hours and haemoglobin reaches predonation level by 3 to 4 weeks of time. So an interval of three
months between t\110 successive donations is sufficient for the males but for females a longer interval of
four or five months may be advocated but again it depends on the urgency of replacement donation and
if need be it can be collected at an interval of three months.
There is another type of donation where patient donates blood for himself i.e. the blood he donates
is used to transfuse the donor later on and this can be termed as autologus donation for autologus
transfusion and will be dealt within appropriate chapter. This blood is collected under different scheme
viz, predeposit scheme, peroperative, intraoperative etc. This advantage in such type of blood is that it
has not to pass through rigorus test procedure and after pre-transfusion tests can be transfused directly.
But then the selection criterion has to be observed and preservation/storage formality has also to be
observed as per recommendation. In case of autologus blood has to be transfused to another person a
written consent from both the party and approval from the treating physician, surgeon is mandatory and
before transfusion all recommended tests (HIV, HbSAg, STS, HCV, malaria) and the pretransfusion test
has to be done before issue of blood collected for autologus transfusion for homologus use.
One of the important step In blood collection is to estimate haemoglobin to know whether the donor
is anemic or not and it can be done by any of the following method:
1. CuSO4 method
2. Sahli's method
3. Cynamethaemoglobin method.
In CuS04 method which is mostly practiced method in the field and in blood bank laboratory. A
blood having 12.5 gmldl of hemoglobin concentration will sink in the CuSO4 solution having sp. gravity
of 1.053 and if it does not pass or float the donor is tested by other method such as Sahli's and
Cynamethaemoglobin method before declaring him anemic) the later is found to bemore accurate and is
based on the principle that potassium ferricyanide converts haemoglobin from ferrous to ferric state to
form methhaemoglobin. The resulting meth-Hb combines with potassium cyanide to produce stable
pigment cynameth Hb which represents the sum of oxy Hb carboxy Hb and meth-Hb.
The hemoglobin level for a donor on an average should not be less than 12.5 gm/dl and to be more
specific 13.1 to 16.5 gmldl for males and 12 to ]4.7 gm!dl for females. The value shows difference
depending on the site of collection viz. blood obtained from ear lobe puncture gives approximately 6%
higher than obtained by simultaneous finger prick. Again blood obtained by finger prick shows hemoglobin
value 2% lower than that of venous blood simultaneously collected from the same donor. All these are to
be taken into consideration for declaring the prospective donor as anemic.
Two unit collection system
Apart from the conventional gravity collection system by which we can collect only one unit ofblood at
one time, a recently introduced method ofTwo Unit Cell Collection from a sin~le
donor by an automated
process.
This is a short procedure of about 30 to 35 minutes where blood is collected from a single 31m. A
donor friendly procedure with all automatic monitoring and thus safe. A closed automatic process with
simultaneous leucodepletion ensures collection of two unitsof red cells, concurrent red cells and plasma,
If precollection test for haemoglobin and all mandatory tests are done it ensures the quality and safety of
blood so collected.
It is very useful, cost effective, blood collection system that can maximise the collection of blood
from the existing donor pool and can meet the increasing demand for red cells.

[[p.18]]
44
Blood Banking and Transfusion
Lightweight portable equipment available in the market are different systems commercially availabl
are Alyx system (Baxter Health Care Corporation) MCS + (Haemonetics) and Trima (Gambro).
3.5
STORAGE~
PRESERVATION, ANTICOAGULANT
The blood collected for transfusion is also a tissue containing cellular element and plasma,Like all othe
human tissue, it is liable to decomposition and this is in contrast to our objective or purpose of bloo
collection (for transfusion). As such to preserve the blood and check deterioration of its components WI
are to provide the blood in vitro with an atmosphere conducive to its preservation in a fluid state. And t(
maintain the fluidity of blood it must be preserved in a suitable anticoagulant, cells must be provided witl
nutrient and biochemical environment in which the rate of metabolismis kept in a lower state, we mus
also ensure a longer shelf life for each unit of blood as blood is a scarce substance that cannot be
produced. It has been further observed that to keep the rate of glycolysis lower it has to be preserver
continuously at low temperature. If the temperature goes above the reconunended range' of 4°C ± 2°e
the rate of metabolism in cells will be enhanced and similarly the enzymatic activity. And if it goes belov
the recommended 2CC utilisation of nutrients by cells may be hampered and moreover the ternperatun
is closer to freezing point may result in rupture of cells accidentally, So the optimum temperature has t(
be maintained continuously. A sustained research for such an ideal solution lead to discovery 0
anticoagulant preservative solution. Hustin, Agote and Lewishon were the pioneers in the field. Louti
and Mollison ultimately was able to prepare the ideal solution suitable for the purpose (ACD). Thi:
anticoagulant with proportionate amount of blood if-collected in a closed container and kept continuously
at the recommended range of temperature, a longer shelf life of twenty one days can be assured for tht
particular unit without much deterioration of the contents and functional property of red cells. And 70%
of red cells maintained the viability in vivo after 24 hours post transfusion.
Anticoagulant
It was found that citrate is the most suitable anticoagulant and 0.20/0 of which can prevent clotting
approximately of 2.5 litres of blood, citrate is used as Trisodium citrate (dihydrate). It exhibits its
anticoagulant effect by chelating calcium, on mixing with blood it removes the calcium (ionised) by
forming a soluble but nonionised chelate compound. Prevention of clotting blood is, therefore, achieved
and blood is maintained in a fluid state.
Nutrition
Citrate though maintains the haemofluidity it was unable to maintain the viability and functional property
of red cells. To maintain the cell metabolism and release of energy in the process through Embden
Meyeroffpathway and pentose phosphate pathway respectively known as anaerobic and aerobic glycolysis
is essentially required for supply of nutrition. And Rouse et al. observed that glucose/dextrose can do
this function satisfactorily. Glucose from plasma passes into the cells by diffusion and is converted into
lactate during process of glycolytic breakdown. The metabolic intermediaries formed are ATP, 2-3 DPG,
NADH (Nicotinamide adenine dinucleotide) NADPH (Nicotinamide adenine dinucleotide phosphatase)
and GSH (glutathione reductase), are for maintenance of cellshape, structure and function and also
regulation of oxygen transport. The rate of glycolysis is influenced by pH and presence of inorganic
phosphate. Rate is increased in alkaline pH and decreases at acidic at pH, and pH 6.5 it may even stop.
Presence of inorganic phosphate enhances the rate of glycolisis irrespective of pH value. Apart from
haemoglobin the intracellular metabolic intermediary like 2-3 Diphosphoglycerate and adenosine
Triphosphate plays important part in regulation oxygen transport, 2-3 diphosphoglycerate through the

[[p.19]]
Blood Banking
45
oxygen affinity for Haemoglobin. DPG profoundly lowers affinity for oxygen. ATP through maintenance
of red cell membrane function. So supply of glucose, dextrose to blood in vitro is necessary to maintain
the red cell functions, pH and Biochemical environment is also necessary so that deleterious effect on
red cell is least. Trisodium citrate is alkaline and if an acid could be added an optimal pH can be
maintained, A weak acid such as citric acid was found suitable for the purpose. Citric acid also prevents
caramelisation of glucose. Solutions are to be autoclaved for making them sterile, Caramelisation of
glucose occurs during autoclaving, But addition of excess citric acid may lead to hypocalcimia in patient
particularly in multitransfused patients. So citrate level has to be restricted to minimum possible.
Temperature
Freshly collected blood has a temperature approximately around 30°C and after collection, it is stored in
a blood bank refrigerator where the temperature gradually comes down. The preservation of blood at
lower temperature is required to preserve viability of red cells, prevent proliferation of bacterial growth
that might have gained entrance during needle prick. Further at lower temperature cell metabolism is
slower with reduced glycolysis rate. And optimum temperature suitable and ideal is 4°C ;t 2°C. This is
for whole blood but it may differ in case of blood component viz. platelet, FFP,labile coagulation fact.or
etc.
So the ideal anticoagulant preservative solution introduced in 1943 was Acid citrate dextrose (ACD)
with a shelf life of 21 days. Further research and development on this showed that addition of phosphate
increases the shelf life further and thus citrate phosphate dextrose solution was introduced with shelf
life varying between 28 to 3S days. With addition of adenine the shelf life increased to 42 days and the
anticoagulant solution is known as CPDA. A list of commonly used anticoagulant with their composition
and property is given in Table 3.4.
Table 3.4. Commonly used anti-coagulants are ACDA, ACDB, CPO, CPDA-1 their composition and
property as listed below
-
.Co~position
ACDA(USP)
ACDB(USP)
CPD(USP)
CPDA (USP)
: Trisodium citrate
22gm
13.2gm
36.3 gin
26.3gm
Citric acid
7.3gm
4.4gm
3.2gm
3.2gm
Sodium dihydrogen phosphate
-
-
2.2gm
2.22gm
Dextrose
24.5gm
14.7gm
25.5gm
31.9 gm
Adenine hydrochloride
-
-
-
O.35gm
Water for injection
lOOOml
lOOOml
lOOOml
lOOOml
Volume/loo ml
l5mVlOOml
25mVlOOml
14mVlOOlnl
14mVlOOmJ
Shelf life 4°C ± 2°C
21 days
21 days
21 days
28-35 days
Use
Preservation
Preservation
Preservation
Preservation
of blood for
of blood for
of blood for
(1) Blood and red
transfusion
transfusion
transfusion
cell for transfusion
(2) Exchange trans-
fusion, infants
transfusion

[[p.20]]
46
Blood Banking and Transfusion
Advantage with CPDA1
CPDAI (USP) has following advantage over others. Better initial survival, longer RBe preservation, net
loss of intracellular 'K' is less, blood remains alkaline i.e. pH is maintained. Better preservation of 2-3
DPG Other coagulant not in common use are Heparin, CPDA-D, Sag Mannitol and Paggs-sorbitol.
Sodium Heparin (USP) : 75,000 IV Heparin sodium in 1000 ml of isotonic saline solution. Shelf life
is 48 hours at 4°C ± 2°C used mainly as anticoagulant in heart lung machine. To be used 6 ml of
anticoagulant solution. per 100 ml of blood. Disadvantage being utilisation must bewithin 48 hours as it
gets neutralised by antiheparin and thromboplastin material released from cellular element of blood.
CPDA-D : It can preserve red cells from 35 to 42 days with haematocrite up to 80% and contains
more adenine and glucose than CPDA-l solution.
Sag Mannitol and Paggs sorbital can preserve red cells respectively for 42 days and 49 days within
recommended temperature range. Haematocrit varying between 75% to 80%. The Sag Mannitol contains
Mannitol, sodium chloride, adenine hydrochloride and glucose monohydrate. The pags sorbitol contains
guanosine, sorbitol, sodium chloride, disodium hydrogen phosphate, glucose monohydrate, sodium
hydrogen phosphate H20, adenine hydrochloride.
Storage lesion
The whole blood that is preserved in anticoagulant preservative solution for the recommended period in
recommended range of temperature undergo certain physical and biochemical changes (Table 3.5)
during this period and these are known as storage lesion. Most important among them are :
(i) Fall in pH value
(ii) Fall in 2-3 DPG value
(iii) Fall in ATPvalue
whereas there occurs an increase in free haemoglobin concentration, free potassium concentration and
the lactate concentration.
Table 3.5
CPDA solution at 4°C
ACD solution at 4°C
Plasma value
0
7
14
21
28
35
0
7
14
21
days
days
days
days
days· days
days
days
days
days
Glucose mg/IOO ml
405
300
Z36
186
142
116
330
280
240
220
Potassium meqllit
4
59
n
88
95
102
7
14
19
23
Sodium meq/lit
173
125
III
102
94
81
160
159
157
153
Haemoglobin mg/too ml
37
53
103
204
353
277
5-10
15
25
50
pH at 37°C
7.04
6.92
6.80
6.65
6.58
6.55
7
6.87
6.73
6.62
Ammonia meq/lOO rnl
1.3
6.3
9.8
13
16
2D
50
260
470
680
Apart from the changes in plasma described as above there was appreciable change in ATP and DPG
level. In CPD blood 2-3 DPG is better maintained then ACD. The DPG concentration in ACD stored
blood falls to 20l}b of its value in the first week and 10% after two weeks. In CPDA solution, the DPG
remains close to normal after one week but it drastically falls to a very low level after three weeks in
both ACD and CPDA solution. Similarly ATP is reduced to 10% during two' weeks in ACD blood where

[[p.21]]
Blood Banking
47
as in CPDA solution the ATPis maintained in a much better concentration and is around 3.88 Ilmol/g Hb
so the loss is negligible in CPD then ACD.
DPG is responsible for oxygen regulation and in stored blood reduced DPG reduces the oxygen
release, because DPG increases oxygen affinity of Hemoglobin. ATP loss preceeds changes in red cell
shape and viability of red cells.
The physical changes that occurs in stored blood at 4°C:
(a) Change in shape of RBe from biconcave disc to sphere
(b) Loss of membrane lipid and lipoprotein occurs gradually during 21 days storage in ACD.
(c) Increase in viscosi ty.
(d) Screen filtration pressure increases in banked blood is attributed to microaggregates formed
during storage.:
(e) Critical haemolytic volume decreases in banked blood. CHV is the volume attained by red cells
when it swells to maximum before rupture.
(f) Increase in cellular rigidity i.e. loss-in deformability of cells.
(g) Changes in osmotic fragility occurs and it tends to increase gradually during storage.
(h) Spontaneous lysis may also occur in some cases.
All these changes described above are collectively known as storage lesion and they are responsible
for reduced PTS of cell. PTS or post transfusion survival of red cell is the capacity of red cell to survive
in circulation after being transfused and this is related to viability of red cells. There occurs progressive
loss ofviability which is directly proportional to the period of storage and also it is influenced by the type
of anticoagulant preservative solution used. With the increasing period-of storage the proportion of cells
removed during first 24 hours post transfusion also increases and thereafter, rapid removal of all cells
takes place. Blood stored in ACD for 21 days has a 70%, 24 hours PTS, i.e., 70% of cell survives in
patients/recipients circulation after 24 hours of transfusion whereas in CPDA solution has higher 24
hours PTS even after 28days storage, i.e.more than70%. CPDA is thusa better anticoagulant preservative
solution insofar the PTS is concerned. Further observation lead to gradual replacement of ACD by
CPDA solution and now-a-days it has become the anticoagulant of choice for preservation of whole
blood.
Preservation and storage of other blood component commonly stored blood components are plasma,
cryoprecipitate, .platelet and red cells.
Plasma is stored in two forms as Fresh Frozen Plasma (FFP) and Frozen Plasma (FP), and both can
be stored in mechanical or deep freezer. The FFP is prepared from fresh blood within six hours of
collection and frozen plasma may be prepared any time even after six hours and both stored at a
temperature of -30°C. They are to be thawed and reconstituted before use. Cryoprecipitate separated
from thawed FFP and the final product is stored at a temperature -40°C to -60°C. Platelet is available as
platelet reach plasma' and platelet concentrate and is commonly stored at a room temperature (20°C to
24°C) with continuous and gentle agitation by horizontal back and forth movement. It has a shelf life of
72 hours and to maintain pH around 6 at least 40 to 50 ml of plasma is required as suspending medium.
At a temperature of 1°C to 6°C the plasma used is 30 to 35 ml and platelet stored without agitation. It has
a shelf life of 48 hours. Before use it has to be warmed to room temperature and resuspended. Discovery

[[p.22]]
Fig. 3.7. Ultralow freezer (-150°C to
195°C) operator wearing cryogloves
to bring out frozen bags from liquid
nitrogen atmosphere.
48
Blood Banking and Transfusion
of a second generation container, a non-polyvinyl plastic container, which help escape of CO2 and
thereby maintain pH around 6.5 and consequently have longer shelf life of platelet :
(i) 5 days with PL-732 CLX (liquid second generation container).
(ii) 7 days with CLX-II and 10 days with CLX-7.
Platelet can also be frozen using 4 to 6% Dimethyl sulphoxide as cryoprotective agent and can be
stored at a temperature of - 80°C to -120°C. It has longer shelf life and is useful for autologus and HLA
typed platelet preparation.
Cryopreservation of red cell in frozen state
The main component of blood, red cell is more important from transfusionist point of view because
there are rare blood groups which are not easily available at short notice so if it can be preserved for a
longer period in form of packed cell useful purpose may be served at the time of need.
So after sustained research it was found that red cells can be preserved for a longer period in a
frozen state i.e. by lowering temperature for preservation below freezing and creating a condition by
which red cells are cryoprotected. It necessitates a change in physical environment around red cell. But
it is technically very difficult to maintain the red cells in a frozen state because of its water content
which freezes resulting in formation of ice crystals that ultimately cause rupture ofred cell and haemolysis,
slow freezing gives rise to bigger crystal formation. So search for an agent-cryoprotective agent which
binds the water and prevents ice formation lead to discovery of glycerol as an ideal cryoprotectant for
human use because it has the property of rapid diffusion through red cell membrane above 4°C allowing
pretreatment of red cells before freezing and it has least harmful effect, addition of glucose to glycerol,
i.e., a mixture of glycerol fructose can act as both intracellular and extracellular cryoprotective agent.
Also hydroxyethyl starch (HES) which has similar non-penetrating property like fructose . But now-a-
days only glycerol is used to keep red cells cryoprotected in frozen state. High glycerol content is
required viz. 40 to 47% if we want to preserve in deep or electro-mechanical freezers and low glycerol
concentration viz. 14 to 17% is required to keep the cells preserved in liquid nitrogen. And in both cases
pretreatment of cells with glycerol is necessary and the process
is known as glycerolisation. There are different methods for
freezing the red cells but the two most commonly used
techniques are :
I.
High glycerol slow freeze of Merryrnen, and
2. Low glycerol rapid freeze of Akerblom-Hogman.
In both the process erythrocytes used should be fresh
and in any case not more than seven days of post collection
period. The erythrocytes are obtained by centrifuging whole
blood in CPD at 3000 rpm for seven minutes and supernatant
plasma is removed. Erythrocytes thus obtained are now treated
with glycerolising solution.
In high glycerol solution (40% w/v final concentration)
using slow freeze technique glycerolising solution consisting

[[p.23]]
Blood Banking
49
of glycerol, sodium lactate, potassium chloride and phosphate (maintain the required pH) is added to the
processed packed cell at ambient temperature (diffusion rate of glycerol is more above 4°C) in two
stages. For packed cells weighing 150 grn to' 230 gm appropriate volume of 6.2 M glycerol solution
required approximately 300 ml. And this amount is added to packed cell in two stages as follows. 100 ml
in the first stage with vigorous shaking of collecting bag for at least two minutes. Balance is added
slowly at the end of two minutes. The glycerolised red cells are now transferred to soft non-plastic bags
(polyolefine bags) centrifuged and supernatant removed and is frozened first and then stored. Freezing
is done at -80°C for 30 minutes and it can be stored at -50°C to -70°C in mechanical freezer (deep
freezer electrically operated). In low glycerol solution (14% w/v. final concentration) using rapid freeze
technique the glycerolising solution consists glycerol, mannitol and sodium chloride. The whole blood is
processed to packed cells as described above and equal volume of glycerol solution is added slowly to
equal volume of red cells with continuous shaking at ambient temperature till equilibrium is reached then
the content is transferred to a plastic bag which is again kept in a upright position in a metal container
commonly aluminium and is stored in vapour phase liquid nitrogen refrigerator for two minutes. Freezing
is done for two minutes at -190°C to -196°C "first and the frozen blood is stored at -150°C. Special
precaution during storage is to keep a close observation on liquid nitrogen coolant in storage chamber
which may get depleted due to failure of other attached devices.
Preservation of red cells by both the process is upto 3 years.
When required for use the red cells has to be deglycerolised and reconstituted in such a way that red
cells are restored to their previous level suitable for transfusion in other words normal physiology' of red
cells are to be restored. First step is thawing of the content of bag at 37 to 39°C by keeping in a water
bath with continuous slow agitation ofwater in such a way that bag containing red cells remain submerged.
Once thawing is completed proceed to next step.
Second step is reconstitution commonly done by agglomeration or centrifugation in continuous
flow cell washing centrifuge.
Agglomeration is based on the principle that red cells clump and rapidly sediment when exposed to
glucose. These clumps can be dispersed by addition of saline. The process avoids use of centrifuge and
can be repeated. Basically the intracellular environment of red cells in glycerolised state are hypertonic
so successive treatment of those cells with progressively less hypertonic solution and finally with
isotonic solution then suspending cells in isotonic saline solution will bring the red cells to normal
osmotic balance and glycerol to a permissible limit of 1% in which form the red cells has a shelf life of
24 hours and to be transfused within that period. Temperature has a vital role to play in preservation of
blood and it has to be continuously maintained at a level prescribed for the particular component and
except for platelet almost all the blood and blood components are preserved and stored at a low temperature.
Interruption may reduce the PTS and may cause multiplication of any dormant bacteria (might have
gained entrance during venepuncture). As such shifting of blood from one room to the other should
involve minimal exposure to outside atmosphere and the refrigerators or walk in cooler etc. are placed in
closed vicinity so that a cold chain system is maintained that will in fact help to provide minimal exposure
to blood and blood components. To maintain cold chain system in a blood bank:
1. Walk in cooler and/or blood bank refrigerator, Donor room, working laboratory, deep freezer
liquid nitrogen freezer, component separation laboratory are designed to be placed in close
vicinity.

[[p.24]]
50
Blood Banking and Transfusion
2. Walk in cooler and B.B. refrigerators must have provisions which maintain uniformity of
temperature throughout the interior chamber or chambers.
3. .It is better to store processed blood, unprocessed blood, blood component, blood infected and
seropositives separately.
4. All cold units must have alternate source of current supply.
5. In addition blood bank must have its own generating set to produce current to take over during
the total current failure.
6. Lastly while transporting blood to ward/OT etc. from blood bank quickest possible transfer is
to be done and if distance between two is more than blood baglbottle to be transported in small
icebox made of thennocole material which can be disposed off.
Container
It is important in storage of blood and blood component. A proper container is required to provide its
content the adequate physical environment that is necessary for its preservation and at the same time
does not interfere with its property - physiological, physico-chemical etc. So the container should
preferably be made of a sturdy inert substance and thus glass bottles were used till recently for storage
and preservation of blood and components. Now-a-days bags has replaced the bottles. The plastic bag
was first discovered by Prof. Carl W. Walter of Harvard Medical School, USA, after a tireless effort of
14 years (1947-1961) and the bags were introduced in USA after extensive clinical trial by FDA in 1962.
Bags definitely has advantage over the bottle.
I . Light in weight
2. Easy transport
3. Less space is required
Sale/litebag
I,
I
I. I
I"
•Breakabe rod
...- Connecting lube
Primary bag
Side
slit
Primary bag
Tamper-proofcase
(TP case)
Hub
Blood
collection
needI
Blood
collection
tube
Fig. 3.8. Closed system collection in single
blood bag .
Fig. 3.9. Double blood bag system.

[[p.25]]
Blood Banking
51
4. More resilient absorbs shocks and jerks and Jess liable to breakage
5. Chance of air embolism and/or bacterial contamination is almost nil
6. Disposable - no washing or sterilisation is necessary discarding through incinerator is easy
7. Component separation and preservation is better
8. Pressure infusion is possible
9. Collection of blood is easy for all the systems areinbuilt
10. Segments contain small amount of blood which can be used for pretransfusion tests.
These plastic bags are made of Polyvinyl 'chloride to which plasticizer Diethyl HexyJ phthalau
(DEHP) is added to provide necessary clarity and flexibility to bags. It was later found that the esters 0:
DEHP leaches out from the bag into the blood and thus it accumulates in tissue of recipients. At 4°(
after the end of storage total phthalate level has been found to be about 7 mg/IOO mJ and which is weI
within the maximum permissible limit of 10 mg/l 00 ml of blood. But the research result showed tha
leached phthalate increase PTS. Even though no other ill effects were discovered the scientist tried t(
develop P.V.C. with less or no plasticizer and following bags were developed :
(a) cLX mar~
II contains DEHP and Tri (2 ethyl hexyl) trimalleate.
(b) F 702 contains triethyl hexyl Benzene tricarboxylate as plasticizer.
(c) PL-732 bag contains no plasticizer and are soft bags made up of polyolefine used extensivef
for preservation of RBC at frozen state at ultra low temperature and also for preservation 0
platelet.
(d) Ethylene Ethyl acrylate bag contains no plasticizer.
Apart from plastic bags which are the primary container secondary containers to hold the plasti.
bags in static or ambulatory position are also in use.
Metal containers made of aluminium are used to holdthe'bags in upright position in-an "3tmospber,
of ultralow temperature of-150°C to 196°C. The secondary container protects the bags from accidenta
cracking because bags become very brittle at such low temperature.
Secondary containers are also used during transport of bags individual unit or multiple units. Fa
individual unit bags are kept in container made of disposable and thermocole ·material. This type a
.containers are used for short distance travel.
For multiple unit and long distance transport the ice boxes made of metal in which blood bags ar
placed amidst ice crystals are particularly used in outdoor donation camp where blood is temporaril
preserved till donation is over and later transport to blood bank walk in cooler or blood bank refrigeratoi
3.6 PROTOCOL FOR OUTDOOR DONATION CAMP
1. Fix a mutually convenient date with the organiser.
2. Choose the area suitable for conduction of outdoor donation camp - preferably in a school c
community centre with facility for fan and water and resting place. If this is not available a ter
with beds for at-least six people, revolving stand fans and water tankers are to bemade availabl
at place of donation.

[[p.26]]
52
Blood Banking and Transfusion
3. Propaganda material for donor motivation to be taken, and distributed.
4. Set up tables for registration, Haemoglobin estimation by CuS04 method, and weight checking.
5. First aid and emergency drugs must be available in the camp.
6. Refreshment and toilet facility must not be forgotten.
7. Keep ice boxes with ice for proper storage of collected blood. Ice box may be made of metal or
thermocole material and ice packs coloured either by CuS04 or any other colouring agent, kept
in plastic bags, frozen previously in deepfreeze.
8. "Donor cards for issue to donor.
9. Incentive as extra or additional benefit from any side that is even by organisers are to be
discouraged.
Recommended for further reading
1. A Hand Book of Medical Laboratory Technology, V.H. Talib, 1990, sponsored by WHO and DGHS, New
Delhi.
2. Blood Transfusion in Clinical Medicine, P.L. Mollison, seventh edition,
1983~
Blackwell Scientific
Publication.
3. Background Papers, Health and Medical Care Managementfor Central Health Service Officers,
National Institute of Health and Family Welfare, New Delhi.
4. Clinical Diagnosis and Management by Laboratory Method, Tod, Sanford, Davidsohn, Second Indian
edition, 1989, Published in India by All India Traveller Book Sellers (AITBS), New Delhi-Sl.
5. Development Strategies on Blood Transfusion, Dr. R.N. Makroo, Organised by Blood Transfusion
Department, SKIMS and DGHS, Ministry of Health, Sponsored by WHO.
6. Elements of Organisation and Management, Study Materials, S. Muthu, 1990, Indian School of Labour
Education, 151, Santhome High Road, Madras-4.
7. Financial Resource Management, Module 11, l.P. Gupta et al., April·1992, NIHFW, New Delhi.
8. Introduction to Transfusion Medicine, Zarin Bharucha and D.M. Chouhan, First edition, 1990, D.K.
Publishers, GD. Ambedkar Marg, Bombay.
9. National Guide Book on Blood Donor Motivation, 1990, DGHS Ministry of Health and Family Welfare,
GO.l., Nirman Bhawan, New Delhi.
10. Planning for District Health Organisation, Module, l.P. Gupta et al., April 1992, NIHFW, New Delhi.
11. Problems and Managerial Process in Health Care Services, Module-2, J.P: Gupta et al., July 1991,
NIHF.W, New Delhi.
12. Text Book of Blood Banking Sciences, C.M. Zmijewski and WE. Hasler, First edition, 1982, Appleton
Century, Crofts, New York.
13. Text Book of Preventive and Social Medicine, J.E. Park and K. Park, Tenth edition, 1985, MIs Banarsi
Das Bhanot, 1268, Napier Town, Jabalpur; India.