How Prepared Are We To Handle Adverse Reactions & Emergencies In Blood Donation Drives?

Last month we looked into various aspects on definition of an adverse event. Steps to help in grading of severity and categorisation of the complication was laid out in detail. We look at the next step in this edition: We take a closer look at what strategies can be adopted to control/prevent these adverse reactions

The best way to adopt preventive methods is to draw plans for each logical part of the blood donation drive. The following categories cover all these logical portions of the drive

1. Before The Event

it is essential to give a lot of importance to some factors before the blood donation drive. All  stakeholdres (organisations, blood banks, volunteers attending drives and donors) need to be prepared to have a smooth and well organised blood donation drive. Here are some important tips for preparation

a.) Preparation For Donors and Organisations

1. It should be pre-informed to the donors not to wear tight clothing around the arms. It restricts blood flow and can cause bruises, so wear something which is loose and comfortable.
2. It is useful to include the indication of keeping hydrated well before donation.
3. Sufficient and relevant information on the importance and need of blood donation it's health benefits and general Q&A in the reading material (e-material), brochures, posters etc must be presented to donors to keep them mentally and physically prepared

b.) Ambience Of The Venue

1. The venue should be well lit, with low temperature and humidity. There should be natural ventilation -or- fans -or- very effective air conditioning in order to minimise reactions.
2. The venue should be cleaned with disinfectant and mopped up before the blood donation drive.
3. Water container and washroom must be available in the near vicinity of the venue.
4. Direct access to lifts should be available from the venue in case it is not on the ground floor. If lifts are not available, care should be taken when the donors climb the stairs up or down post donation.
5. Infrastructure needs including tables, chairs and other furniture must be made available in advance. 
6. The drive incharge from the blood bank must plan the layout of the drive well in advance (with a strong concern towards proper donor flow, waiting area, medical screening area, pre and post donation area etc)

c.) Essential Training Requirements For Staff and Volunteers

Well trained and professional staff and volunteers are the essence of a successful and safe blood donation drive. Although specific training needs are too huge, in general the staff and volunteers need to be aware of

1. The contributing and mitigating factors associated with complications.
2. Safe needle techniques for VP
3. Counselling the donors to reduce stress and anxiety
4. Ability to converse in local language AND in English with the donors
5. Identification of higher risk of complication and suitable mitigation strategies
6. Understanding of AMT

2. During The Event

After all the preparations for the drive has been taken care of, it is very to have one person incharge of the blood donation drive. This person must have a complete view of all stakeholders, the processes and standards to be followed. He/She must ensure that the following preventive aspects are looked into in the mentioned areas

a.) Pre Donation Counseling

1. A principal role is to reduce potential anxiety in the donor.
2. Observe for donors in a ‘hyper-vigilant’ state and refer where appropriate.
3. Professionalism, including appearance, is crucial in order to assure the donor of a safe and positive experience.
4. Greet the donor with a warm welcome and thank them for attending the session and giving up their time to donate blood.
5. The person needs to promote drinks to the donors. Offer the donor 500 mL of fluid to stretch the stomach (gastric dilation) and raise blood pressure (BP), reducing the risk of vasovagal (VV) episodes. This offer or promotion of drinks must be emphasised quite strongly in order for the donor to understand the importance of taking the fluid. Ideally the fluid should be drunk over 5 minutes rather than sipped, and should be taken no longer than 30 minutes prior to donation for best effect. 
6. If possible, donors who are queuing to give their details should be offered fluids along with an explanation of why there is a delay.
7. Donors who are waiting to be screened must not be seated facing the cots. The eyes of all waiting donors ideally need to be focused away from clinical activity.
8. Ensure all donors are given the Welcome information to read prior to screening.

b.) Medical Screening

1. Enquire as to whether the donor has had any previous problems when donating blood and try to relieve any anxiety.
2. If a previous adverse event is identified or the donor has an increased risk of an adverse event, a technician/nurse should be asked to speak to the donor. The technician/nurse will also instruct the donor on how to do applied muscle tension (AMT) exercises to raise the BP if appropriate. 
3. Ask the donor if they have drunk the recommended volumes of fluid prior to the screening. If they have not, it needs to be explained to the donor why drinking fluids is important and offer again. If the donor agrees to drink, give the fluids while talking.
4. Ensure new donors and those with a previous history or higher risk of VV episode(s) are indicated in some way. This will help easily identify those with a higher risk of complication or adverse event.
5. Once screening is complete, show the donor to the waiting area, which must not have chairs facing the beds. Magazines and reading material should be available as a method of distracting the waiting donors from focusing on the clinical area. It is important to reduce tension and anxiety that will be experienced by many first-time donors and those who may have had a problem donating or an adverse event in the past. Additional fluids could be offered at this point too.
6. The risk of complications is directly associated with the volume of blood the donor is eligible to donate. It is vitally important to accurately measure the hemoglobin and the weight of the donor. The blood banks must follow a standardisation and validation process before each drive to check the accuracy of the hemoglobin measurement and weight measurement.
7. While measuring hemoglobin the technician must take care to ensure
8. proper usage of lancet,
9. use of capillary tube(against touching the donor's finder to any non-disposable surface or glass slide),
10. discard of the first drop of blood,
11. usage of freely flowing drop of blood for test and
12. changing the CuSo4 solution after every few(20-25) tests.
13. While measuring hemoglobin by the electronic equipment, it is strongly advised to use CuSo4 in parallel and verify the readings using the cell counter when there is disagreement between the two techniques.
14. Ask the donor about their preparation for giving blood:

• have they had something to eat before attending the session,
• have they slept well,
• if they have smoked in last 2 hours,
• if they have taken alcohol in last 24 hours,
• if they have taken any medication,
• if they have they involved themselves in doing any strenuous activity or exercise that may increase their risk of an adverse event.

c.) Donation Area

1. Do not ask the donor to remove foot ware. Attempt to put on the shoes later may trigger re-bleeding.
2. Greet the donor and speak to them. Watch for any signs of anxiety or hyper-vigilance. Calm the donor down by speaking for a few seconds before you start cleaning the arm.
3. Prioritise donors and provide appropriate therapeutic attention. Talking to donors will allow you to recognise their coping strategies and how best to put them at their ease. Ensure that less experienced technicians do not get to bleed the donors who are more likely to have discomfort.
4. If the previous adverse event was related to double pricks and other localised complications, ask the donor for the preferred arm for donating blood.
5. If required, in order to raise the donor’s BP, once they are on the bed, ask the donor to commence AMT exercises. This keeps their mind occupied as they are counting and their focus away from the venepuncture (VP).
6. Do not leave the donor before starting VP. Aim to have the pack labeled and VP started promptly to prevent the donor’s BP from being affected.
7. Good needle insertion techniques reduce the frequency and severity of localised complications.
8. Distracting the donor by means of playing music helps reduce changes of generalized reactions. 
9. If an adverse event occurs, a nurse should decide if it is clinically necessary to screen off the donor to ensure privacy for the person involved and to avoid raising anxiety levels in those who are waiting. Screens should be placed around the donor, but initially, if necessary, place your body between the donor and the waiting donors to block their view until screens arrive. Donors should never be left unattended behind a screen.
10. Once the donation is complete, remove the needle and cover the VP site with gauze, asking the donor to apply firm pressure with three fingers to the dressing. If necessary a pressure bandage if a haematoma is developing.
11. Stay with the donor until they leave the bed. Use the time to complete any observations, give advice to the donor, assess pallor and ensure the donor is applying the correct pressure to their arm.
12. After 2 minutes the site is observed, do so by lifting the gauze without removing it, to protect the donor from any blood splash. This also shields the donor from seeing the VP site. If there is no new bleeding, apply the dressing.

• Always move the needle forward in a slow ongoing movement.
• If the needle is not inserted in the vein at the first attempt, it is not advisable to do a second try by moving the needle a little bit backwards, change direction, and then move forward again in a new direction, as this will increase the risk of injuries and occurrence of haematoma, and thereby the risk of a severe complication.
• Never try to insert the needle twice, using the same puncture site. Instead try the other arm.
• Never ask for or give help if insertion was not a success, as this will always include a try in a new direction.

d.) Refreshment Area

1. Ensure the refreshment area is such that it does not obscure your direct vision of the donors.
2. Ensure there is adequate space around the table and chairs in case of falls and potential head injury.
3. Stress to donors who refuse a drink, the importance of having a post-donation drink to replace fluid depletion.
4. Encourage new donors and those with a previous VV episode to have cold drinks.
5. Deal with re-bleeds promptly. Try to ensure nearby donors see as little as possible. Have provision in post donation area to manage re-bleeds.
6. If a donor becomes unwell, stay with them and call for assistance.
7. When giving post-donation advice, take care not to embarrass donors or trigger other donors to listen in to the conversation.
8. Observing the donor during and after donation, treating the donor if a complication occurs and making sure the donor feels absolutely well before leaving the blood session.
9. Give advice to the donor on secondary bleeding, driving, rest and return to work after the donation.
10. Asking the donor to contact the blood establishments if symptoms are seen.
11. At the first signs of vasovagal complications, try to get the donor in recovery position as soon as possible. Preferably rest the donor on the closest flat surface and elevate the legs. Attempts to move the donor to the bed could aggravate the complication.

3. Other General Considerations

The correlation of the following aspects with adverse events has not been studied in detail. However, they are widely reported, acknowledged and accepted as influencing factors complications:

1. Any sight of blood is likely to trigger vasovagal reaction. As far as possible, there should be no blood drops in sight of the donors. The glass slides and lancet used for hemoglobin assessment should be disposed in containers which keep the sight of blood drops away. Further, any spillage of blood should be handled immediately.
2. Spillage of oral fluids, vomiting, involuntary urination etc. lead to unpleasant surroundings which sometimes contribute to vasovagal reactions. Besides, they could also lead to injuries related to the falls. All attempts should be made to contain the spillage such that it is out of sight of the donors while the housekeeping arrives. This could be done using sheets or cartons which are available.
3. Direct visual contact with a person who is suffering from a complication is known to trigger further complications. Attempt must be made to shield off the person who is recovering from other donors.
4. Messy surfaces with cotton swabs, paper wrappings of consumables, scattered packaging materials etc. create an unpleasant donation site which is likely to aggravate anxiety and give a sense of incompetent surrounding to the donors. By making proper and strict use of dustbins the site for donations should be kept clean.
5. Crowding around a person recovering from a complication generates curiosity and concern among other people in the camp. This could potentially trigger further reactions. Only those staff members who are directly needed for the recovery of the donor should be come close to the donor.
6. More complications are seen towards the end of the blood donation drive when the focus of the staff shifts from donation management to packing the materials. Resist from moving away from the donor and ensuring equal attention is given till the last person finishes donation.

The next issue shall carry details on management of adverse reactions. 

Through the Patrika an appeal is made to all Blood Bankers to put in practice the methods and tools as mentioned in the protocol. This protocol is a sincere effort from Sankalp India Foundation to make blood donation drives a pleasurable and awesome experience for blood donors. 

Readers are encouraged to bring forth queries, suggestions and ambiguities by writing to sankalp.admin@gmail.com Lets walk together to make voluntary blood donation in India safer.

Important Specific References

1. 1. Distraction techniques:
2. F. C. T. B. Bonk VA, “Distraction reduces self-reported physiological reactions to blood donation in novice donors with a blunting coping style.,”Psychosomatic Medicine 63(3),, pp. 447-452, 2001.
3. 2. Needle Insertion techniques
4. a. Jorgensen J & Sorensen, “Donor vigilance. ISBT Science Series, 3(1)” pp. 48-52.
5. b. Domaine, “Donor Management Manual,” 2010. [Online]. Available:http://www.domaine-europe.eu/Portals/0/Manual/Donor%20Mangement%20Manua….
6. 3. Hydration and Applied Muscle Tension techniques
7. a. J.-A. W. C. R. F. P. L. P. S. J. A. Blaine Ditto, “On-Site Training in Applied Muscle Tension to Reduce Vasovagal Reactions to Blood Donation,” February 2003. [Online].
8. b. B. D. M. E. W. J. L. F. T. D. A. R. K. S. S. M. Z. T. a. E. M. Christopher R. France, “Pre-donation Hydration and Applied Muscle Tension Combine to Reduce Presyncopal Reactions to Blood Donation,” 22 06 2010. [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1111/j.1537-2995.2009.02574.x/abs….
9. c. F. C. Hanson SA, “Predonation water ingestion attenuates negative reactions to blood donation,” Transfusion, pp. 924-928, 2004.
10. 4. Adverse events analysis
11. a. N. M. R. R. S. Naveen Agnihotri, “Analysis of adverse events and predisposing factors in voluntary and replacement whole blood donors: A study from north India,” Asian Journal of Transfusion Medicine, pp. 155-160, 2012.
12. b. (Domaine 2010) Domaine, “Donor Management Manual,” 2010. 
13. c. (Domaine 2007) Working Group on Complications Related to Blood Donation, “Standard for Surveillance of Complications Related to Blood Donation,” 2007.