adult blood transfusion medics

8/6/2019 Adult Blood Transfusion Medics

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Adult Blood Transfusion Policy – Medical Staff SectionSt Mary’s NHS Trust

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1. Requests for blood transfusion and collection of blood samples forpre-transfusion testing:

Doctors should complete the transfusion request forms. If this task has been delegatedthen the person completing the form must put their identity and the identity of theDoctor who has authorised them to do so.

The request form must contain full patient identification details ie surname, firstname, date of birth and the hospital or A&E unique identification number. The requestform must also give:

a) The location of the patient at the time of requestb) Information about past obstetric and transfusion history including details of

known red cell antibodies or previous transfusion reactionsc) The patient’s diagnosis

d) The reason for the request.e) The name and contact bleep or phone number of the doctor making the requestf) If a transfusion is requested the number and type of blood or blood

components, including any special requirements and the time and daterequired.

Emergency Transfusions: The Transfusion Laboratory has internal policies relatingto emergency blood transfusions. It is vital that thelaboratory be verbally informed of any patient requiringemergency transfusion. Special hospital protocols relateto massive blood transfusions (Appendix 3).

Collection of blood samples

Patient identification: Positive identification of the patient is essential based on• questioning the patient by asking their surname, first

name and date of birth, in the case of patients who are judged capable of giving an accurate, reliable response.The information given should be checked to ensure itmatches exactly that on the request form

• on the ward, checking that the details on the patient’sidentification wristband match those on the request formand the answers to the questions above.

NB. If the wristband is removed e.g. to insert a cannula, it is the responsibility of theperson removing the wristband to re-site it.

All patients receiving a blood transfusion MUST wear an identificationwristband.

Sample labelling: the sample tube must be labelled immediately after the

blood has been added, by the person taking the sample.




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• Estimate the volume of lost blood according to Baskett criteria below:

Class I Class II Class III Class IVBlood loss:%volume (ml)

<15750

15-30850-1500

30-401500-2000

>40>2000

Bloodpressure:SystolicDiastolic

UnchangedUnchanged

NormalRaised

ReducedReduced

Very lowVery low/

unrecordablePulse (bpm)

Slighttachycardia

100-120 120 (thready) >120(very thready)

Capillaryrefill Normal Slow > 2 sec Slow > 2 sec UndetectableRespiratoryrate Normal Normal Tachypnoea

>20/minTachypnoea

>20/minUrinary flowrate (ml/hr)

>30 20-30 10-20 0-10

Extremities Colour normal Pale Pale Pale and coldComplexion Normal Pale Pale AshenMental state Alert Anxious or

aggressiveAnxious,

aggressive ordrowsy

Drowsy,confused, orunconscious

Indications for transfusion for acute blood loss

1) Based on the estimation of lost circulating volume:

Volume lost(%)

Volume lost(mls)

Crystalloids andsynthetic colloids

Transfusion

15% 750 mls no *no

15-30% 800-1500 mls yes **Not likely

30-40% 1500-2000mls

Rapid volumereplacement

Probable

40% > 2000 mls Rapid volumereplacement

Definitely

*Only transfuse if: pre-existing anaemia or severe cardio-respiratory disease**Only Transfuse if: pre-existing anaemia, severe cardio-respiratory disease or if bleeding continues

2) Based on the concentration of haemoglobin:




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The concentration of haemoglobin should be considered along with other factors suchas the rate of bleeding:

Haemoglobin

level

Need for transfusion Rate of

Transfusion> 10 g/dl NO

< 7 g/dl Yes Depends on:• Rate of ongoing red cell loss • If patient otherwise is well give

2 units, then reassess7-10 g/dl Not known • Clinicians often transfuse

• Available evidence suggest thisis often not justified

< 8 g/dl Yes, if •

Patients > 65 years• Cardiovascular and respiratory

disease

I. Based on the risk of further bleeding resulting from abnormalhaemostasis:

Abnormal haemostasis caused by acute blood loss is usually caused bythrombocytopenia or platelet dysfunction and should be treated with platelet

transfusion according to the guidelines BCSH, 1988 (see Appendix A2)

Coagulopathies requiring replacement therapy are less common and again should betreated according to the guidelines BCSH, 1988 (see Appendix A2)

Correcting the anaemia in uraemic patients with either red blood cells or Epo oftencorrects the prolonged bleeding time. Similar data in other clinical settings isunavailable

II- ANAEMIA IN CRITICAL CARE:

The same target values should be applied as for acute blood loss.

Over transfusion may increase mortality in this group; 30-day mortality was no worsein patients managed by a “restrictive” transfusion strategy (trigger haemoglobin conc.< 7.0 g/dl) than in patients managed by a “liberal” strategy (trigger haemoglobin < 10g/dl)

Other important considerations are:Adequate volume replacementMaintenance of blood pressure and use of inotropesMaintain a normal cardiac output




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Crystalloid vs. colloids debate continues. Recent systematic review of randomisedcontrolled trials suggested preference for crystalloids (Schierhout & Roberts, 1998) inacutely hypovolaemic patients.

Colloids have the potential disadvantages:

Hypersensitivity reactions including occasional severe anaphylactoid reactionExcerabation of any haemostatic problems

II. PERIOPERATIVE TRANSFUSION:

The objective should be to manage the patient so that transfusion is not needed.There is no case for transfusing back to normal haemoglobin either before or aftersurgeryAvoid transfusion when the haemoglobin > 10 g/dl in line with current good practice

Specific measures that may be appropriate are:Investigation and treatment of anaemia before elective surgeryDiscontinuation of antiplatelet agentsReversal of anticoagulationConsideration of various strategies for autologous transfusion (BCSH, 1997)The use of pharmacological agents to reduce surgical bleeding

The same approach to the management of acute haemorrhage during surgery shouldbe applied as for acute blood loss.

IV. CHRONIC ANAEMIA:

The cause of anaemia should be established and treatment with red blood cell shouldnot be given where effective alternatives exist unless the anaemia is life threatening.

Many patients with chronic anaemia are apparently asymptomatic with a haemoglobinaround 8 g/dl

Recombinant Epo is an alternative in chronic anaemia, which has been used to treatanaemia in some patients with cancer, myeloma, myelodysplasia and lymphoma.

It has been found to be safe and effective in some patients who show a sustainedincrease in haemoglobin concentration. The high cost of the drug has limited its use.

Special situations:

Thalassaemia• The goal of transfusion in these patients is to: suppress erythropoiesis; inhibit

the increased gastrointestinal iron absorption and to correct the anaemia.• Hyper-transfusion programmes that cause substantial iron loading have been

supplanted by regimens in which, the haemoglobin concentration is no more

than 9.5 g/dl before transfusion. Such protocols provide adequate bonemarrow suppression and lower rates of iron overload.




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Sickle cell disease (SCD)• Long-term transfusion programmes are also used in SCD to:

Reduce the risk of stroke in children at high risk (defined bytranscranial Doppler studies) and in patients with previous stroke and

reduce vaso-occlusive events during pregnancy• A recent randomised trial found that an aggressive preoperative transfusion

strategy involving exchange transfusions did not reduce the number of post-operative vaso-occlusive complications compared with top-up transfusions toa haemoglobin concentration of 10 g/dl, and had the disadvantage that red cellalloimmunisation was twice as common.

• Transfusion in not routinely indicated for patients with SCD when thehaemoglobin concentration is < 7.0 g/dl. Specialist centres should be contactedfor specific advice about individual patients.

3) Guidelines for the issue of platelets, fresh frozen plasma andcyroprecipitate:

a) PlateletsBiomedical Scientists (BMS) can issue platelets without authorisation by theHaematologists (SpR or Consultant) for the following circumstances:

1. Thrombocytopenic patients following cytotoxic chemotherapy who haveplatelet count < 20 x 10 9 /l with fever and or bleeding.

2. Asymptomatic thrombocytopenic patients following cytotoxic chemotherapywho have platelet count < 10 x 10 9 /l.

3. Patients newly diagnosed with acute leukaemia undergoing Hickman lineinsertion have a platelet count < 50 x 10 9 /l.

4. Patients with acute lymphoblastic leukaemia or other haematologicalmalignancy with CNS involvement requiring lumbar puncture and having aplatelet count < 50 x 10 9 /l.

5. Patients undergoing cardiopulmonary bypass surgery who are bleeding (evenwith platelet count > 80 x 10 9 /l) as these patients commonly have plateletfunctional defects, especially if aspirin was not stopped 7-10 dayspreoperatively.

6. Patients undergoing or about to undergo surgery and having a platelet count <80 x 10 9 /l. If time allows, the thrombocytopenia should be investigatedpreoperatively.

7. Patients undergoing emergency epidural analgesia or operative delivery withplatelet count < 80 x 10 9 /l. When time allows, the thrombocytopenia should beinvestigated antenatally.

8. Patients with disseminated intravascular coagulation (DIC) and massivetransfusion with platelet count < 50 x 10 9 /l or if the platelet count is rapidlyfalling.

Platelets are strongly contraindicated in:




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1. Patients with suspected or confirmed thrombotic thrombocytopenicpurpura/adult haemolytic uraemic syndrome (TTP/HUS).

2. Patients with suspected or confirmed heparin-induced thrombocytopenia(HIT).

3. Pregnant mothers with Haemolysis Elevated Liver enzymes and Low Platelets

(HELLP).

Platelets are usually not indicated in:

Patients with immune thrombocytopenia.

Platelets should not be issued for a patient with newly diagnosedunexplained thrombocytopenia without examining the blood film foraggregates, red cell fragments and platelets without discussing it with theon call Haematologist.

Platelets are not normally held in stock by the blood bank and need to be ordered fromthe National Blood Transfusion Centre in Colindale. Delivery of platelets may take upto 2 hours. Platelets are supplied as an adult dose and only one pool will be issued ata time.

Special platelets products:These include single apheresis units, HLA-matched, irradiated, and CMV-seronegative platelets (all platelets are leucodepleted) which may be made availableon request for the appropriate use and after discussing it with the Haematologists

preferably during routine working hours.

b) Fresh Frozen Plasma (FFP)FFP is indicated for the following patients:

1. Disseminated intravascular coagulation (DIC).2. Urgent reversal of warfarin when treatment with vitamin K is inappropriate or

would not produce a sufficiently rapid response.3. Single coagulation factor deficiency for which no factor concentrate is

available.4. Plasma exchange in patients with confirmed thrombotic thrombocytopenic

purpura / adult haemolytic uraemic syndrome (TTP/HUS).

BMS can thaw FFP without authorisation by the Haematologists (SpR or Consultant)for the following patients:

• Actively bleeding patient (in the absence of coagulation results, urgentsamples MUST be sent to the laboratory for coagulation screen andplatelet count).

• The INR is > 1.7 and the patient is bleeding/oozing.• The INR is > 1.5 prior to invasive procedures.• The INR is > 1.3 prior to liver biopsy.• Massively transfused patients (see specific protocol).




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The starting dose of FFP is 12-15 ml/kg and bags of FFP are either 280 or 300 mls insize. FFP is stocked frozen, in the blood bank, it takes 30-40 minutes to thaw. TheFFP must be used within 4 hours of thawing.

FFP SHOULD NOT BE USED:

• As plasma expander in hypovolumic patients.• In plasma exchange of patients with conditions other than confirmed

thrombotic thrombocytopenic purpura / adult haemolytic uraemic syndrome(TTP/HUS).

Cryoprecipitate (Cryo)

BMS’s can thaw Cryo without authorisation by the Haematologists (SpR orConsultant) for the following patients:

• Disseminated intravascular coagulation with fibrinogen < 1.0 g/l.• Hypofibrinogenaemia/dysfibrinoginaemia with bleeding.• Massively transfused patients with fibrinogen < 1.0 g/dl

4. Administration of blood and blood components:

Prescription of blood and componentsThe prescription of blood and blood components is the responsibility of the doctor.The prescription should be written on the “continuous or intermittent intravenoustherapy” section of the drug chart and it is essential that this sheet should contain thepatient identification details.

The prescription must specify:• The blood or blood component to be administered, including any special

requirements e.g. irradiated, CMV seronegative• The quantity to be given• The duration of the transfusion (usually 3 hours for red cell concentrate and 30

minutes for an adult pool of platelets or a unit of FFP)• Any special instructions including any medication required before or during the

transfusion e.g. diuretic cover.

NB. Blood Transfusion must be treated like any other prescription i.e. patients (orrelatives) should be informed of the indication for the transfusion, its risks andbenefits. Signed consent is not required. An information leaflet is available fromBlood Transfusion. It is strongly recommended that the indication for thetransfusion is stated in the hospital notes.

5. The management and reporting of adverse events

• If a transfusion reaction is suspected because the patient complains of symptomsor there are changes in observations, a member of the medical staff looking after




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the patient will be contacted immediately by the nursing staff. The patient’stemperature, pulse and blood pressure should be recorded. Further managementdepends on the type and severity of the reaction.

• If a severe reaction is suspected:1. the transfusion should be stopped and urgent medical advice sought

2. the blood administration set should be changed and venous accessmaintained using normal saline to keep the vein open

3. the reaction should be reported immediately to the Blood TransfusionLaboratory. The implicated unit should be returned to the laboratory alongwith the blood samples from the patient (6ml EDTA x 2 and 1 clottedsample) and a sample of the first urine passed since the transfusion, havingfirst performed and recorded a dipstick test for haemoglobin.

4. nursing observations should be carried out at regular intervals5. the volume and colour of any urine passed should be recorded and

dipsticked

If a severe reaction is suspected, medical advice from a Haematologist should besought.

6. The documentation of transfusion

A permanent record of the transfusion of blood and blood components must be kept inthe medical notes including. The entry in the case notes, describing the indication forthe use of blood or blood components, the date, the number and type used, whether ornot the transfusion achieved the desired effect and the occurrence and management of

any adverse effects.

The above documentation is essential so that any serious adverse effects of transfusion can be adequately investigated and audit trails followed satisfactorily.

7. Responsibilities of various staff groups within the bloodtransfusion process

Many groups of staff are involved in one or more aspects of blood tranfusion. Some

procedures are specific to one staff group, but many can be carried out by more thanone.

1. Medical staff are solely responsible:• for prescribing appropriate blood, blood components and blood products• ensuring adequate documentation regarding the requirement for blood transfusion

in the medical notes.• Requesting blood and blood components. In an emergency situation medical staff

may delegate the requesting of blood to nursing staff but it is the doctor’sresponsibility to ensure that the person they delegate the task to has all therequired information, including the doctor’s name and bleep.




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2. Medical and/or nursing staff may carry out the following actions and beresponsible for:

• Taking blood samples for compatibility testing • Requesting blood and blood components in emergency situations where the doctor

has delegated the task • Explaining the risks and benefits of blood transfusion to patients • Carrying out the procedure for the administration of blood and blood components• Monitoring patients during transfusion, and carrying out the appropriate actions in

the event of adverse effects • Reporting of transfusion reactions or other incidents related to transfusion




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Appendix 1MANAGEMENT OF MASSIVE ACUTE BLOOD LOSS PROTOCOL

Activate when anticipated blood loss is 10 units or more in 1-2 hours

RING

IN WORKING HOURS

Mon – Fri 9am -5pm

1 Blood Bank ext 2043(Emergency use only)

2 Haematology ext 6540

OUT OF HOURS

1 Bleep on-call MLSOBleep 1611

STATE

1 Activate “Massive Bleed Protocol”

2 Patient Identification3 Your location4 “Urgent Sample”

2 units of O Rh D Negative uncrossmatched blood(available immediately)4 units of type specific uncrossmatched blood(available 5 minutes after receipt of sample)Number of crossmatched units required(available 30 minutes after receipt of sample)

1 pool of platelets (1 hour minimum)3 acks of FFP ½ hour minimum

REQUEST

SENDCrossmatch Sample : 6mls EDTA

(purple) fully labelledDO NOT continually ring lab to check progress

SEND FBC4.5 ml in EDTA

ur le

1 Clotting screen2 Fibrinogen

4.5 ml in citrate

blue

REPEAT

FBC, Clotting Screen, Fibrinogen immediately following infusionof Platelets/FFP/CryoState on Request form which products have been infused prior tosample collection

AIM FOR:-

Platelets > 50 x 10 9 /L, INR < 1.5, APTR < 1.5, Fibrinogen > 1.0 g/L




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Appendix 2

Complications of transfusion

Problem Cause Timing in relation to

transfusion and frequencyof occurrence

Severity of resulting clinical

condition, management andpreventionAcute complicationsAcute intravascularhaemolysis of transfusedred cells

ABO-incompatibletransfusion, e.g. Group Ablood into group Orecipient. Usually occursdue to simple clericalerrors e.g. taking samplesfor compatibility testingfrom the wrong patient ortransfusing blood to thewrong patient

Often during the first fewmls of transfusion.Reported to occur in 1 in600,000 units transfused.

Mortality approximately 10%due to DIC and acute renalfailure.Management: considerpossibility of DIC and renalfailure. Maintain the bloodpressure and renal perfusion.Transfuse compatible redcells. Prevention:use safedocumentation and checking

systems for bloodadministration

Febrile nonhaemolyticreactions

1) Anti-leucocyteantibodies in patient,who has beenpregnant orpreviouslytransfused, reactingagainst leucocytes inthe transfused blood.

2) Cytokines in storedplatelets

Towards the end of theinfusion or within hours of completing thetransfusion.Frequency: Rare now thatfiltered blood is in generaluse

Unpleasant but not life-threatening.Treatment: paracetamol orother antipyretic.

Urticaria Antibodies in patient toinfused plasma proteins orinfusion of allergenswhich react with IgEantibodies in the patient.More likely to occur withtransfusions of platelets orplasma than red cells

During the transfusion.Frequency:1-2% of transfusions

Unpleasant but not lifethreatening.Treatment: givechlorpheniramine 10-20mgi.v./i.m.Prevention: premedicate withchloropheniramine 10-20mgbefore transfusion in patientshaving recurrent episodes.

Anaphylaxis In some cases antibodiesare found patients against

IgA in the transfusedblood; these patients areoften deficient in IgA.

Very rare May be life-threatening.Management:maintain

airway. Give adrenaline0.5mg IM every 5 minutes asrequired andchlorpheniramine 10-20mgby slow i.v. injection of adrenaline every 10 minutesuntil improvement occurs.Prevention: use washed redcells and platelets, plasmafrom IgA deficient donors, orautologous blood.




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Appendix 2 (continued)


Problem Cause Timing in relation totransfusion and frequencyof occurrence

Severity of resulting clinicalcondition, management andprevention

Infective shock Bacterial contamination of red cells or platelets withe.g. Pseudomonas,Yersinia or Staplococci

Usually during infusion of first 100 ml of thecontaminated pack.Rare: 2 per million bloodcomponents transfused.

Very high mortality.Treatment: management of septicaemia. Fluid andintravenous antibiotics

Transfusion-related acutelung injury (TRALI)Noncardiogenicpulmonary oedema

Donor plasma (usuallyfrom multiparous women)contains antibodies torecipient’s leucocytes.

Clinically, there is anacute respiratory reactionwith fever, cough andshortness of breath andtypical appearences on thechest X-ray

During or soon aftertransfusionFrequency: rare

May be life-threatening.Management: mainatainairway. Manage as for acuterespiratory distress

syndrome.

Delayed ComplicationsDelayed haemolysis of transfused red cells.

Patient has IgG antibodiesto red cell antigens such asRh, Kidd, Kell, Duffybecause of previouspregnancies ortransfusions. Theantibodies areundetectable in thecrossmatch, but furthertransfusion causes asecondary immuneresponse resulting indelayed haemolysis

5-10 days after transfusionFrequency: Less than 1 in500 red cell transfusions

Poorer than expectedresponse to transfusionTreatment: no treatmentneeded per se , but antibodieswill be a problem for furthertransfusion. The hospitalblood bank should record thepresence of red cellantibodies in the patient’scomputer records, and thisinformation should beavailable when compatibilitytesting is carried out in thefuture.

Transfusion-associatedgraft-versus-host disease(TA-GvHD)

Immune reaction of donorT cells against therecipient who is oftenimmunodeficient, e.g.bone marrow allograftrecipient, Hodgkin’sdisease, fetus receivingintrauterine transfusion.Clinically, there is fever,skin rash, liver and renalfailure and pancytopenia.

4-30 days post transfusionFrequency: rare,approximately 1 in750,000 units of cellularcomponents transfused.

Usually fatal.Treatment: seek specialistmedical advice.Prevention:irradiation of cellular components forsusceptible recipients




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Appendix 2 (continued)


Problem Cause Timing in relation totransfusion and frequencyof occurrence

Severity of resulting clinicalcondition, management andprevention

Post-transfusion purpura Immune-mediatedthrombocytopenia, usuallyoccurring in parouswomen. Antibodiesagainst human plateletantigens (HPAs) aredetectable in the patient’sserum, usually anti-HPA-1a

5-12 days post transfusion Thrombocytopenia is usuallysevere and may causebleeding.Treatment: platelettransfusions are ineffectiveand the treatment of choice ishigh-dose intravenousimmunoglobulin 0.4 g/Kgbody weight of the patientdaily for 5 days.

Prevention: for futuretransfusions, use appropriateHPA - negative red cells andplatelet transfusions.

Post-transfusion viralinfection

Viral infection in thedonor is not detected bydonor screening andtesting.

Depends on virus: weeksor months post-transfusionFrequency: HIV <1 in 3million and <1 in 200 000for both HBV and HCV

Depends on virus.Management: seek specialistmedical advice

Iron overload One unit of red cellscontains 250 mg of iron

After several years of frequent transfusion

Causes liver and cardiacdamage.Prevention: usedesferrioxamine to increaseiron excretion in patientsreceiving long-termtransfusions.

adult blood transfusion medics

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