Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,

Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health

BLOOD COMPONENTSWHAT DO YOU NEED TO KNOW?

Janine CarnellTransfusion Nurse Consultant

Eastern Health

MYTHS AND LEGENDS

Egyptian princes, knights and royalty bathed in it – resuscitate the sick and rejuvenate old and incapacitated

Warriors, hunters and Romans drank it – from dying gladiators (such blood was especially beneficial since the athletes were strong and brave)

Used as a sacrifice to the Gods by ancient American and Mexican Indians.

In England, blood from newly executed criminals was a curative (prescription required).

BLOOD TRANSFUSION HISTORY In 1667, Dr. Jean-Baptiste Denys (physician to King

Louis XIV of France) transfused the blood of a sheep into a 15y.o. boy who survived the transfusion (small amount)

The first successful human-to-human blood transfusion• 1818-1829 by eminent British obstetrician and physiologist

James Blundell (PPH: husband to wife).

5 out of 10 of his subsequent transfusions were successful. Many other examples Karl Landsteiner discovered A, B + C (O) groups 1901.

• 4th major group (AB) reported by Decastello and Sturli in 1902.• Around 1937, discovery of the Rhesus blood group system –

which was found to be the cause of the majority of transfusion reactions up to that time

Today, to meet the annual needs of patients, Victoria collects approx: 250,000 blood donations, 78,000 plasma donations and 9,000 platelet donations

WHO USES BLOOD?

RED CELLS (>200MLS)

Treatment of clinically significant anaemia with symptomatic deficit of oxygen carrying capacity

Replacement of traumatic or surgical blood loss

Paediatric (25-100mls) – infants, young children and intrauterine transfusion (RCH)

Special Red cells - i.e. irradiated, washed, fully phenotyped, CMV negative, whole blood, directed donations, autologous blood

Use blood of identical ABO and Rh(D) type whenever possible. In an emergency situation, Group O Rh(D) Negative blood should be

given while the patient's blood group is being established. One unit of red cells raises the haemoglobin concentration in an average

sized adult by approximately 10 g/L. Red cells are filtered to remove most leucocytes and may be resuspended in

other additives to prolong storage.

Although important, the patient’s haemoglobin level should not be the sole deciding factor for giving red cells.

CONSIDER

RBC transfusion should not be dictated by a Hb concentration alone, but should also be based on assessment of the patient’s clinical status.

Where indicated, transfusion of a single unit of RBC followed by clinical reassessment is appropriate.

HAEMOGLOBIN CONSIDERATIONS

<70 g/L Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available.

70–100 g/L Likely to be appropriate during surgery associated with major blood loss or if there are signs or symptoms of impaired oxygen transport.

>80 g/L May be appropriate to control anaemia-related symptoms in a patient on a chronic transfusion regimen or during marrow suppressive therapy.

>100 g/L Not likely to be appropriate unless there are specific indications.

PLATELETS Therapeutic – Bleeding due to decreased platelet production

or functionally abnormal platelets Prophylaxis – rapidly falling or low platelet counts

<10 x 109 /L secondary to cancer or chemotherapy or bone marrow failure without risk factors

<20 x 109 /L in bone marrow failure in the presence of additional risk factors (e.g., fever, antibiotic or evidence of systemic haemostatic failure)

Maintain >50 x 109 /L for most surgical procedures; and >100 x 109 /L for surgeries with high risk of bleeding (e.g., ocular or neurosurgery)

Apheresis (100-400mls) – single donor Pooled (>160mls) – 4 donations Paediatric (40-60mls) – infants, as above

One standard dose (1 pack apheresis or 1 pooled) would be expected to increase the platelet count of a 70 kg adult by approx 20–40 x 109 /L

NB. ALL platelets from ARCBS in Victoria are universally leucodepleted and irradiated. Check labelling

FFP (FRESH FROZEN PLASMA) Patients with coagulopathy who are bleeding when

specific therapy (such as Vitamin K or factor concentrates are unavailable)

To replace labile plasma coagulation factors during massive transfusion, cardiac bypass, liver disease or acute disseminated intravascular coagulation in the presence of bleeding and abnormal coagulation

Double split (250-334mls) Triple Split (250-310mls) Paediatric (~60-80mls) is separated from a single unit of whole

blood and then divided into 4 packs. Reduce donor exposure and minimise product wastage

Volume depends on clinical situation, patient size and laboratory tests.

General guide is 10 -15mL/Kg per dose.

Given in addition to Vit.K in warfarin overdose Warfarin Reversal Guidelines (Vit.K, PTX, FFP)

CRYOPRECIPITATECryo (10-40mls) Treatment of fibrinogen deficiency with clinical bleeding, an

invasive procedure, trauma or disseminated intravascular coagulation

Massive transfusion

Apheresis (60mls) 1 unit of cryoprecipitate apheresis is approximately equivalent to 2 units of cryoprecipitate derived from whole blood

A common dose for fibrinogen replacement is 30–40 mL cryoprecipitate for each 10 kg patient body weight (~5 – 10 units)

Prepared by thawing FFP and recovering the precipitate. The cold-insoluble precipitate is refrozen.

It contains most of the factor VIII, fibrinogen, factor XIII, von Willebrand factor and fibronectin from FFP.

BLOOD MANAGEMENT GUIDELINESNHMRC, ASBT, NBA6 MODULESModule 2: Perioperative Minimise requirement Promote appropriate useIdentify high risk patients, and develop a specific

management plan ahead of time

Clinical Guidance Effect of anaemia on outcomes Effect of blood transfusion on outcomes Cessation of medications that affect haemostasis Peri-operatvie strategies to minimise blood loss

Prevent hypothermia, positioning, deliberate hypotension, cell salvage

Triggers for transfusion – coagulation parameters Anaesthesia and Patient Blood Management

BLOOD MANAGEMENT GUIDELINES

Pre-Op managementAnaemia – optimise Hb and iron storesHaemostasis management – warfarin, aspirin, NSAIDs considerations

Blood Conservation Strategies Pre-op Pre-operative Autologous Donation (PAD)Intra-op Acute Normovolaemic Haemodilution (ANH) Cell SalvagePost-op Cell Salvage

Appropriate transfusion practice

Transfuse in accordance with clinical practice guidelines

INDICATIONS FOR BLOOD IN THEATRE

Elective surgery– well planned

Emergency – chaotic

Acute blood loss

Obstetric – blood loss unpredictable (intra-op, post-op)

Hb levels and surgery

Levels 70-100g/L – transfusion likely to be appropriate if major

blood loss or S/S of impaired O2 transport

Bleeding disorders (acquired/congenital) – liver disease, aspirin-

induced platelet dysfunction, DIC, thrombocytopaenia,

haemophilia

Anti-coagulated patient – be aware

MBOS – Maximum Blood Order Schedule – local hospital policye.g. Arthroscopy (nil), Caesarean (G+S), Open Prostatectomy (2units)

RISKS IN THEATRE

Checking remains VITAL Emergency or Elective Crossmatched or Emergency Uncrossmatched Unconscious or Unidentified patient Local hospital policy

Remote or Satellite fridge Must have a detailed register of products in and

out Audit trail between Blood Bank and Theatre Alarmed, monitored, maintenance schedule Rapid access Protection from public Multiple theatres – multiple units in fridge

Source - Toonpool.com

CURRENT RISKSTRANSFUSION TRANSMITTED INFECTION

“Australia has one of the safest blood supplies in the world in terms of viral safety.” – ARCBS

Source – ARCBS website July 2012

Risks of Transfusion-transmitted Infection Calculated on Blood Service Data

Agent and testing standard Window period Estimate of residual risk ‘per unit’

HIV (antibody + NAT) 5.6 days Less than 1 in 1 million

HCV (antibody + NAT) 3.1 days Less than 1 in 1 million

HBV (HBsAg + NAT) 23.9 days Approximately 1 in 764,000

HTLV 1 & 2 (antibody) 51 days Less than 1 in 1 million

vCJD [No testing]   Possible, not yet reported in Australia

Malaria (antibody)  7–14 days Less than 1 in 1 million

Notes: vCJD=variant Creutzfeldt-Jakob Disease; (a) The risk estimates for HIV, HCV, HBV and HTLV are based on Blood Service data from 1 January 2010 to 31 December 2011.

INFORMED CONSENT Informed consent for transfusion means a documented dialogue

has occurred between the patient and a prescriber :

The reason for the proposed blood product transfusion.

The nature of the proposed blood product transfusion – what is involved

The risks and benefits of the blood product as well as the risks or

consequences of not receiving the product.

The availability and appropriateness of any other blood management

strategies.

An opportunity to ask questions.

Use of a competent interpreter when the patient is not fluent in English.

Use of written information or diagrams where appropriate.

Be aware of local hospital policy

Specific consent form? Generic Consent form? Request slip? Progress Notes?

Who signs? Doctor? Patient? Witness?

Refusal?

DOCUMENTATION – BLOOD TRANSFUSION Variation in forms and requirements across Health Services Know hospital policy

Request slip Patient details, components required, urgency, modifications, indications,

prescribers and collectors signatures…

Blood release form Where, what, who…

IV orders/Prescription for blood – specific, detailed Date, timing, terminology, special requirements, urgency…

Compatibility report form Details of component, patient ID, crossmatch compatibility…

Observation charts, Fluid Balance Charts, Progress Notes

Specific blood obs, what is documented in notes…

Adverse event form / Transfusion Report Form Reactions, errors, also consider Hospital incident reporting systems

Consent requirements

EQUIPMENT – FILTERS

Stored blood contains blood clots and particles that are potentially

fatal to the recipient.

This can cause pulmonary complications and death

It is essential that there is an integral in-line filter in the giving set

to administer a blood product

This filter (170-200 micron) removes clots and small clumps of debris that

may form during collection and storage.

All red cells and platelets issued by the Blood Service are leucocyte

depleted

Therefore additional bedside leucocyte depletion filters are NOT required.

Microaggregate filters (pore size 20-40 microns) are intended to

remove microscopic debris from stored red blood cells.

There is no evidence from controlled trials that they offer clinical benefit and

their use is not generally recommended.

EQUIPMENT – IV LINES IV Lines

Must contain an inline filter (mesh in/above the drip chamber)

Primed with normal saline or the blood component

Must not be piggy-backed onto another line

Attachment to extension tubing on an IV cannula/multi-lumen venous access

device is acceptable

How many units can be put through a single IV line?

Any number provided the flow remains adequate – if the line becomes clogged – change it

Usually the entire transfusion episode

Must be changed when transfusion is complete/every 12 hours if not yet complete

reduce the risk of bacterial growth occurring

Generally speaking – if there is mesh in/above the drip chamber – this is an inline blood filter and you DO NOT need any additional filter

Generally speaking – if there is mesh in/above the drip chamber – this is an inline blood filter and you DO NOT need any additional filter

IV FLUIDS

N/Saline

4% albumin

Plasma protein fractions

ABO compatible plasma

Morphine,or Ketamine or Pethidine (diluted in normal saline)

Gelofusine

x Calcium containing solutions (e.g. Hartmann’s, Haemaccel) – may cause clotting in line

x 5% dextrose – may cause red cells to haemolyse

x Most medications – need to flush the line before and after administration

Compatible Incompatible

The only IV fluid universally compatible with blood components is 0.9% sodium chloride (normal saline)

EQUIPMENTPUMPS, PRESSURE DEVICES, RAPID INFUSERS, SYRINGE DRIVERS

Pumps

may be used to prevent problems with slow flow rates or clogging

paediatric patients, or those at risk of fluid overload

PICC, CVAD

monitored hourly throughout the infusion to ensure that expected volume is delivered

Pressure Devices and Rapid Infusers

used with large volumes of red cells in the setting of critical bleeding

usually also warm the red cells

Must be monitored at all times during use

Syringe Drivers

Paediatric use –need to ensure that blood passes through 170-200micron filter

Continuous transfusion of coagulation factors

EQUIPMENTBLOOD WARMERS

Not usually required in routine transfusions The use of a blood warmer is often advised for:

o Large volume rapid transfusions of;o >50 mL/kg/hour in adults or o >15 mL/kg/hour in children

o Exchange transfusionso Plasma exchange for therapeutic apheresis in adults. o Intrauterine transfusions, at the discretion of the feto-

maternal specialisto Patients with clinically significant cold agglutinins

Red cells must not be warmed above the set point temperature of the approved device, commonly 41°C.

DO NOT warm blood in hot water, microwave, radiators or under your arms!

PRE-TRANSFUSION CHECK

The last place we can make sure we are giving the right

blood to the right patient

Consequences of failure in checking process:

Right Blood – lucky it arrived for the right patient

Wrong blood – compatible – good luck

Wrong component – (e.g. CMV negative, irradiated etc.. )

Puts the patient at risk of adverse event – sometimes this

can be delayed

Wrong blood – incompatible – this can result in severe

transfusion reactions and even death

PATIENT IDENTIFICATION Local hospital policy No ID Band = No Blood?

In emergency situations, a process should be in place for cases where a patient is unable to be identified

Hospitals must have a written policy on the requirements for patient identification

Many health services will specify: Patient ID – Surname, given name, DOB, UR number Additional identifiers e.g. gender, address, Medicare number Neonates – 2 ID bands? Unconfirmed identity – name changes – “unknown female” 2 approved staff members must carry out the Patient ID

check prior to blood transfusion

PRE-TRANSFUSION CHECK

If ANY discrepancy – DO NOT transfuse

All done at the BEDSIDE

Blood Bag Patient ID Documentation

OBSERVATIONS Temperature, pulse, respiration rate and blood pressure MUST

be measured and recorded : Prior to the start of each individual blood component pack administered 15 minutes after commencing administration of each blood component pack When administration of each blood component pack is completed There is no consensus on subsequent frequency of routine vital sign

measurement during transfusion, however many institutions stipulate hourly measurements, after the initial 15 minute period, until completion of the transfusion.

Regular visual observation throughout the transfusion is

essential

Blood Pressure, Temperature, Pulse, Respiratory Rate Baseline

15 minutes

Hourly from commencement time

Stop time

Remember – most transfusion reactions occur within the

first 15 mins of transfusion

TRANSFUSION RATES The infusion rate for blood products depends on the

clinical context, age and cardiac status of the patient. In stable, non-bleeding adult patients typical

administration durations are: Red cells 60-180 minutes per unit Platelets 15-30 minutes per standard adult

dose FFP 30 minutes per unit (i.e. 10-20mL/kg/hr) Cryoprecipitate 30-60 minutes per standard adult

dose (i.e. 10-20mL/kg/hr).

Note – in an emergency you are limited only by the size of the cannula

TIME LIMITS Commence transfusion within 30 minutes of arrival

from Blood Bank If returned to the BB within 30mins it can be returned to the

fridge and then released to any other patient as required. Once it has been at room temp for >30mins it cannot then

be used for any other patient – you then have up to 4 hrs MAXIMUM to complete the transfusion

Transfusion must be complete within 4 hours Risk of bacterial proliferation greatly increases when unit is

at room temp for >4 hours

TRANSFUSION REACTIONS Local hospital policy Recognise, React and Report Most common adverse reaction = fever

Mild Reactions include: Fever, rash,

Moderate to Severe reactions include: Fever, hypotension/shock OR hypertension, tachycardia,

tachypnoea, wheeze, stridor, rigors or chills, nausea, vomiting or pain (local, chest, back)

Reporting requirements Flow chart to follow? Report form to complete? Investigations required? Documentation?

TRANSFUSION REACTION IN AN UNCONSCIOUS PATIENT

May occur after only 5-10 ml

In a rapid emergency transfusion – signs may only be evident after several

units

Extra care must be taken in the unconscious patient to monitor and react to

changes in vital signs

Possible Signs of a Severe Adverse Reaction to

Transfusion in an Unconscious Patient

Temperature rise more than 10C

Pink or red urine (hemoglobinuria)

Increased operative bleeding

Hypotension

Reduced urine output

Tachycardia or bradycardia

NURSING MANAGEMENT Recognise

that signs and symptoms may be due to the transfusion React

immediately STOP transfusion assess and manage patient, follow policy review documentation (in particular check the pt’s ID band

against blood bag and compatibility report form) Report

to HMO and Blood Bank

Document: (local hospital policy) Transfusion Report Form and/or Incident report Progress notes Investigations – pathology slip

TRANSFUSION REACTION FLOW CHART

MANY OTHER RESOURCES ARE AVAILABLE

RESOURCES / ACRONYMS

Australian Red Cross Blood Service (ARCBS) http://www.transfusion.com.au/

Australian and New Zealand Society of Blood Transfusion (ANZSBT) http://www.anzsbt.org.au/

Australasian Society of Blood Transfusion (ASBT)

National Blood Authority (NBA) http://www.nba.gov.au/

National Health and Medical Research Council (NHMRC) http://www.nhmrc.gov.au/guidelines/publications/cp78

Blood Matters Program – Department of Health http://www.health.vic.gov.au/bloodmatters/

Local hospital policies

QUESTIONS?

Janine CarnellTransfusion Nurse Consultant

Eastern Health

Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,

Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health