Vasovagal Reactions in Blood Donors

H. OGATA, N. IINUMA, K . NAGASHIMA, AND T. AKABANE

From the Blood h n k Secrion, University of Shinshu Medical School Hospiral, Matsumoto. Japan

The donor records of a hospital blood bank, analyzed from a statistical standpoint, demonstrated a low inci- dence of vasovagal reactions: 119 in 10,547 donations (1.13%). Donors of younger age and of lower diastolic blood pressure were more prone to reaction. There was no significant sex difference. Higher reaction rates were also associated with first-time donation, the time of year (spring), and a particular phlebotomist. Thelow reaction rate and the clearly demonstrated psychologic factors in the present study were attributed to a reflection of the small amount (200 ml) of blood withdrawn. The importance of the phlebotomist-donor relationship was stressed.

THIRTY OR MORE years ago, when the statis- tical information about the vasovagal reac-

and the phys- iological process was clarified by experi- m e n t ~ , ” ” ~ it became obvious that many physiological and psychological factors pre- disposed to vasovagal reaction. Presently, donors still experience the reactions, and the transfusion service must do all it can to prevent these incidents.” There are many potential donors who hesitate to donate for fear of fainting.

Our initial purpose was limited to the pre- diction of the potential reactors and to the prevention of the reaction in our own phle- botomy room. We noticed a difference be- tween our patients’ conditions and those of patients described by earlier investigators. A 200-ml unit of blood is usually collected from one donor in Japan, whereas others collect more than 400 ml from their donors. In the present study, actual reaction rates were measured instead of making a comparison between a reactor and control group, since the number of reactions was so small. The

tion was compiled3,7.1 l . l 2 . l ’ , 16

Received for publication September 14,1979; accepted November 4, 1979.

collected data, however, seemed to be quite reliable, because most of the blood collection during the survey was performed by a limited number of people: a clerk, two phlebotomy nurses, and a physician.

Materials and Methods The subjects were 10,547 donors to our hospital

blood bank, who were bled between May 1976 and March 1978. The majority of them were family members, relatives, and acquaintances of the patients of our hospital.

The donors checked off a list of questions on their donor cards. For each donor, a physician took a history and recorded body temperature, blood pressure, and pulse rate. Donors were se- lected and bled on the basis of criteria for donor suitability of the Japan Red Cross Blood Center.” For each donation, 200 ml of blood were collected into either glass bottles or plastic bags, unless the bleeding had t o be stopped before this amount was obtained. The times for bleeding varied from about 3 t o 10 minutes. Following the collection of blood, the donor was given coffee and was asked to sit for a while.

Phlebotomy was performed, for the most part, by two experienced nurses who had been trained for blood bank procedures. They had been in- structed regarding donor reactions, and a physi- cian in charge was available a t any time in the phlebotomy room. Approximately 4 per cent of the donors were bled by a third, less experienced, nurse and by several physicians.

In case of donor reaction, the donor was placed in a supine position with the lower extremities elevated. Vasoconstrictor drugs were not used. Various data pertaining to the reaction were re- corded by the nurses under supervision of the physician.

Results A total of 119 donors experienced vasovagal

reactions (Table 1). This was 1.13 per cent of the

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680 OGATA ET AL. Transfusion November-December 1980

Table 1. Vasovagal Donor Reactions in 10,547 Donors

Immediate Delayed Total Per Cent ~ ~~~

Slight 97 13 110 1.04 Moderate 4 3 7 0.07 Severe 2 0 2 0.01 Total 103 16 119 1.13

total 10,547 donors. The reactions were classified into three classes.” The reactions associated with unconsciousness and involuntary movement were classified as “severe,” and those associated with unconsciousness were classified as “moderate.” The remainder were“s1ight” reactions. Most of the reactions(l10) wereslight,and therewereonlytwo severe reactions.

The donor population consisted of 2,847 women and 7,700 men. Of these, 91 men had reactions (1.18%) and 28 women had reactions (0.98%). The difference was not significant(P >O. I). There was a tendency ( P < 0.01) that younger donors were more likely to develop reactions(Fig. 1). There was a significant decrease in the frequency of reactions between 20 and 30 years of age in women ( P < 0.05), and between 30 and 40 years of age in men (P < 0.01).

A significant correlation was found between

diastolic blood pressure and frequency of reactions ( P < 0.025): the lower the diastolic pressure, the higher the frequency (Fig. 2). There was an apparent decline in the frequency of reactions associated with an increase of body weight (Fig. 2). However, the association was not significant ( P > 0.05).

There was a higher incidence of reaction at the first donation (Table 2). The association was significant (P < 0.00 1). One year was divided into four seasons (Table 2), as is usual in Japan. The reactions were most frequently encountered in the spring, and the frequency was rather low in sum- mer, when the temperature and humidity are highest. The association between season and fre- quency was statistically significant ( P < 0.001).

In our blood bank, most of the phlebotomies were carried out by two specialized nurses. Nurse A had I 1 years of experience and nurse B had six years of experience. Donor records disclosed that vasovagal reactions were more frequently asso- ciated with phlebotomist B than with phlebotomist A ( P + 0.01) (Table 2).

Discussion Many physiological and psychological fac-

tors predispose to vasovagal donor reaction, and they intert~ ine . ’~ The physiological fac-

7%\ o Female

Age I 16 - 20 21 - 30 31 - 40 41 - 50 51 - 60 FIG. I . Reactions related to sex and age of the donor.

Volume 20 Numhcr h

mm Hg.

VASOVAGAL REACTIONS 68 1

60 70 80 90 10 0 I 1 1 I

Table 2. Donor Reactions Related to Previous Donation, Season, and Phlebotomist

1.5%

1.0%

0.5%

Kg

Previous Donations

50 55 60 6 5 70

0 ~ ~ ~~~~

1 2 or More No Record

Number of donors 3820 2486 3948 Number of reactions 73 28 18 % of all cases 1.9 1.1 0.45

293 0 0

Spring Summer Autumn Winter (March) (June) (September) (December)

Number of donors 2545 2851 3022 Number of reactions 47 28 20 % of all cases 1.86 0.98 0.66

2169 24

1.11

Phlebotomist ~~ ~ ~

Nurse A Nurse B Others ~~

Total

Number of donors 4410 5714 423 Number of reactions 35 76 8 O/O of all cases 0.794 1.330 1.891

10547 119

1.13

o d i a s t o l i c pressure X body weight

OGATA ET AL. 682 7 ranifusion Novernbcr-Decernhcr 1980

tors have been extensively analyzed.2'3*4.7712''5 Authors have stressed the influence of the donor's per~onality, '~ nervousness,6 atmos- phere of the bleeding room," and the staff's personal touch.Ib

Our situation appeared to differ from that of previous authors, because we collected only 200 ml of blood from each donor (the usual amount in Japan), which is less than half the amount described in previous reports. Therefore, it was expected that our results were influenced by psychological factors more than in the previous investigations. The reaction incidence of 1.13 per cent is low in comparison with the incidence of 5 per cent suggested by previous rep~rts.~,~,',"-'~,'','~ Reaction rates as high as 15.2 per cent6 and as low as 2.49 per centI3 have been reported.

The amount of blood drawn plays a major role in determining the incidence of the reaction.'' We do not believe our low inci- dence is directly related to a racial differ- e n ~ e . ~ . ~ A volumic physiological effect is not clearly evident in the relation between body weight and reaction rate as reflected by the overall incidence, though a lower reaction rate was seen in our donors with heavier body weights (Fig. 2). Poles and Boycott'' demon- strated a significant difference in body surface areas between fainters and nonfainters. Body surface area, which is more closely related to blood volume, might have shown a closer association to reaction rate than did body weight in our study.

Except for one report,I5 it has been widely recognized that younger donors are more prone to develop vasovagal reactions than older ones. Our results are in agreement. There are opposing opinions about sex dif- fe ren~e .~ '~ ' '~ ' Our study revealed no signifi- cant difference, though the reaction rate was slightly lower in women. Close observation of the age distribution discloses that the reaction rate declined prominently in women between 20 and 30 years of age. A similar phenomenon was seen in men between 30 and 40 years of

age. This may suggest an increased vasomotor stability" during these ages, but a more detailed study is necessary for a definite conclusion.

There have been varied reports about the influence of initial blood pressure on reac- tion rate of donors. N o significant associa- tion was shown in two One report indicated that a high blood pressure and a high pulse rate were often seen before bleed- ing in reactors3 Our study showed a lower reaction rate in the donors with higher dia- stolic pressures. It is in agreement with one other ~ t u d y . ~ The association seems to be reasonable in our situation, because there is probably a positive correlation between age and blood pressure, in addition to the associa- tion between age and reaction rate. Though it was not examined in our study, the correla- tion was seen in the healthy people in our district.'

The higher frequency of reactions in first- time donors has been mentioned repeatedly- statistically significant in one report4 and not significant in three reports.'*l2*'' It can be assumed that first-time donors were in a nervous emotional state, which was reflected in the reaction rate. The significant difference in our study seems to be quite reasonable. Since the physiological factors had less influence in our study than in others, emo- tional status can be expected to have more influence on the reaction rate.

A seasonal difference was found in our reaction rate. Callahan el ~ 1 . ~ studied monthly reaction rates and showed tendencies toward peak rate in the months of April, July, and November. These authors denied climatic association, but gave no explanation for this phenomenon. Previous reports have denied an association between reaction rate and temperature and/ or Spring is the most comfortable season in our district, and the temperature and humidity are highest in summer, but the reaction rate was signifi- cantly higher in spring than in summer.

VASOVAGAL REACTIONS 683 Volume 20 Number 6

Therefore, the seasonal variation in our study also cannot be explained by climatic condi- tions. We assume that the high, spring reac- tion rate is related to psychological factors. Spring is the season of change and social stress in Japan. We have all kinds ofchange in spring-starting school and work, position changes at work, moving, etc. We saw many strained youths in our phlebotomy room in this season.

There was a difference between reaction rates of donors bled by the two phleboto- mists. The two specialize in phlebotomy and pheresis. Nurse A had had 11 years of experi- ence and Nurse B, six years in our blood bank. There seemed to be no technical difference, but there was an obvious difference in nurse- donor communication. The former is cheerful and outgoing. In contrast to her, the latter is shy and quiet, and only occasionally talks to donors. A donor stated “It was not easy to talk to the nurse, as she looked serious.” It is not unlikely that the phlebotomist made donors nervous, which induced vasovagal reactions. This result clearly demonstrated the importance of the nurse-donor relation- ship, which was rather vaguely mentioned in previous studies.’” I

The low reaction rate and the clearly dem- onstrated psychological factors were charac- teristic for the present study. They are con- sidered to be the reaction to the withdrawal of a small amount of blood (200 ml). Among such factors, the phlebotomist-donor rela- tionship is one of the most important factors. The relationship can be improved through increased effort and training. Other factors are useful in predicting vasovagal reactions, but they are probably unchangeable.

References I . Barcroft H, Edholm OG, McMichael J , Sharpey-

Schafer EP. Posthemorrhagic fainting: a study by

cardiac output and forearm flow. Lancet 1944; 1:489.

2. &a1 RW. Vasovagal reactions in blood donors. Med J Aust 1972;2:757.

3. Brown H, McCormak P. An analysis of vasomotor phenomena (faints) occurring in blood donors. Br Med J 1942;1:253.

4. Callahan RC, Edelman EB, Smith MS, Smith JJ. Study of the incidence and characteristics of blood donors ”reactors.” Transfusion 1963;3:76.

5 . Ebert RV, Stead EA, Gibson JG. Response of normal subjects to acute blood loss. Arch Intern Med 1941;68:578.

6. Graham DT. Prediction of fainting in blood donors. Circulation 196 I ; 23 : 90 I .

7. Greenbury CL. An analysis of the incidence of“faint- ing” in 5,897 unselected blood donors. Br Med J 1942;1:253.

8. Hosogaya H. Personal communication. 9. Howarth S . Sharpey-Schafer EP. Low blood-

pressure phases following haemorrhag. Lancet 1947; 1 : 18.

10. Japan Red Cross: Standard procedures in blood centers, 1970 (In Japanese).

11. Moloney WC, Lonnergan LR, McClintock JK. Syncope in blood donors. N Engl J Med 1946; 234: I 14.

12. Poles FC, Boycott M. Suncope in blood donors. Lancet 1942 ; 2 : 53 1.

13. Roeckel 1E. Donor reactions. In: Donor Room Pro- cedures. Washington, D.C. American Associa- tion of Blood Banks, 1977:23.

14. Ruetz PP, Johnson SA, Callahan R, Meade RC, Smith JJ. Fainting: a review of its mechanisms and a study in blood donors. Medicine 1967; 46: 363.

15. Subcommittee of the Blood Transfusion Research Committee. Fainting in blood donors. Br Med J 1944; 1:279.

16. Williams CEO. Syncopal reactions i n blood donors: aninvestigationof222 cases. Br Med J 1942;1:783.

Hiroyuki Ogata, M.D., Blood Bank Pathologist, Blood Bank Section. University of Shin-shu Medical School Hospital. 3-1-1 Asahi, Matsumoto, Nagano-ken, Japan.

Kiyoko Nagashima, R.N., Blood Bank Nurse, Blood Bank Section, University of Shin-shu Medical School Hospital.

Noriko linuma, R.N., Blood Bank Nurse, Blood Bank Section, University ofshin-shu Medical School Hospital.

Taro Akabane, M.D., Professor, Department of Pediatrics, Faculty of Medicine, Shin-shu University; Director, Blood Bank Section, University of Shin-shu Medical School Hospital.