department of haematology and blood ......haematology and blood transfusion laboratory user handbook...

DEPARTMENT OF HAEMATOLOGY AND BLOOD TRANSFUSION

USERS HANDBOOK

This document will be reviewed and updated regularly. The most up to date revision of the handbook will always be available on NHS Borders Intranet. Users will be alerted by global e-mail and by the Intranet “News” page when a new version is published.

All hard copies of this document should be considered uncontrolled. If you print any part of this document it is your responsibility to ensure that out of date copies are withdrawn and destroyed.

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Haematology and Blood Transfusion Laboratory User Handbook - Version: 1.6. Index: Haematology 9833. Printed: 12-Nov-2013 14:55

Authorised on: 26-Jun-2012. Authorised by: Bill Dunsmore (Inactive). Document Unique Reference: 87-35948137. Due for review on: 02-Dec-2013

Author(s): Bill Dunsmore (Inactive)

Haematology and Blood Transfusion LaboratoryUser Handbook

Every effort has been made by the Medical and Scientific staff to ensure that the information contained in this handbook is comprehensive, accurate and useful.

If you have any comments or suggestions for improvement please contact one of the following.

Dr Ashok Okhandiar, Consultant Haematologist, Clinical Head of Department

Mr. Bill Dunsmore, Department Manager Haematology & Blood Transfusion

Mr. Colin Bruce, Area Laboratory Quality Manager

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CONTENTS

1 GENERAL INFORMATION ........................................................................................ 5 1.1 Description of Service .................................................................... 5 1.2 Location ........................................................................................ 5 1.3 Contact Details .............................................................................. 6 1.4 Opening Hours .............................................................................. 6 1.5 Out of Hours Service ..................................................................... 7 1.6 Requesting Tests ........................................................................... 7 1.7 Specimen Collection ...................................................................... 8 1.8 Inoculation Risk Samples ............................................................... 8 1.9 Reports ......................................................................................... 9

2 HAEMATOLOGY ........................................................................................................ 10 2.1 General Haematology .................................................................. 10

2.1.1 The Full Blood Count ............................................................. 10 2.1.2 Blood Film ............................................................................. 10 2.1.3 Reticulocytes ......................................................................... 11 2.1.4 Glandular Fever (Infectious Mononucleosis) Screen ................ 11 2.1.5 ESR ....................................................................................... 11 2.1.6 Malaria and Other Blood Borne Parasites .............................. 11 2.1.7 Bone Marrow Aspiration and/or Trephine Biopsy .................. 12

2.2 Coagulation ................................................................................ 12 2.2.1 INR (Warfarin Control) .......................................................... 12 2.2.2 APTT (Ratio) .......................................................................... 12 2.2.3 Coagulation Screen ............................................................... 12 2.2.4 D-Dimer ................................................................................ 13 2.2.5 Thrombophilia Screen ........................................................... 13 2.2.6 Induction and Maintenance of Anticoagulation ...................... 15

2.3 Haematinics (Vitamin B12 & Folate) ............................................. 15

3 ANDROLOGY (SEMEN ANALYSIS) .................................................................... 16 3.1 Infertility Investigation ................................................................ 16 3.2 Post Vasectomy Screening ........................................................... 16

4 BLOOD TRANSFUSION .......................................................................................... 19 4.1 Mandatory Requirements ............................................................. 19

4.1.1 Training ............................................................................... 19 4.1.2 Minimum Data Set ................................................................ 19

4.2 Provision of Blood and Blood Components .................................. 20 4.2.1 Group and Save Serum ......................................................... 20 4.2.2 Issue of Red Cell Concentrate ................................................ 21

Emergency Issue ......................................................... 21 Neo-natal Transfusion .................................................. 22

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4.2.3 Other Blood Components ...................................................... 24 Fresh Frozen Plasma and Cryoprecipitate ..................... 24 Platelet Concentrate ..................................................... 24

4.3 Transfusion Reaction .................................................................. 24 List of Components and Products Available .................. 24

4.4 Antenatal Screening and Rhesus Prevention ................................. 24 Antenatal Screening ..................................................... 25 Rhesus Immunisation Prevention .................................. 25

4.5 Other Investigations .................................................................... 26 Cold Agglutinins .......................................................... 26 Cryoglobulins ............................................................... 26

APPENDIX 1 – TESTS AND REQUESTS .............................................................. 27

APPENDIX 2 – LIST OF EXTERNAL REFERRAL LABORATORIES. ........ 32

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1 GENERAL INFORMATION

1.1 Description of Service

The Department provides a comprehensive Haematology, Andrology (semen analysis) and Blood Transfusion service to clinicians throughout NHS Borders. This service is provided from purpose built accommodation within the Area Laboratory at the Borders General Hospital site. Where a particular specialised requirement cannot be met locally, the department will contract with approved external laboratories to provide this service (see appendix 2 for a list of laboratories for external referral.

Our departmental team consists of around twenty medical, scientific, clerical and support staff, together responsible for processing in excess of 190,000 request in Haematology and 12,000 in Blood Transfusion annually. Blood Bank issues more than 6,500 units of blood and blood products annually.

The department is equipped with a range of modern analysers appropriate for our current and projected workload. These include: 2 x Beckman Coulter LH780 full blood count analysers2 x Instrumentation Laboratory ACL TOP 500 coagulation analysers 1 x Diamed Gelstation for blood grouping and screeningClinisys Labcentre laboratory information management system (LIMS).

The department is committed to providing a quality service; in addition to a full programme of regular internal quality assurance we are also enrolled in all appropriate, available national external schemes. The laboratory is also committed to maintaining registration and compliance with all relevant accreditation bodies and regulatory framework. Currently the department has achieved compliance with the standards specified by:

Clinical Pathology Accreditation

Blood Safety and Quality Regulations (2005)

Further information on quality may be found in the Laboratory Quality Manual available on request.

The department has been approved by the IBMS as a training laboratory for pre-registration Biomedical Scientists

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1.2 Location

Haematology and Blood Transfusion is located within the Area Laboratory on the 2nd floor of Borders General Hospital.

1.3 Contact Details

Departmental Address

Department of Haematology and Blood TransfusionArea LaboratoryBorders General HospitalHuntlyburnMelroseRoxburghshire TD6 9BS

Telephone (018968) 26247 Haematology Laboratory(018968) 26248 Blood Transfusion Laboratory

Fax (018968) 26237

Key PersonnelExtension/Bleep E-mail

Dr. Ashok OkhandiarConsultant Haematologist

(018968) 26233Bleep 26233Secretary as above

[email protected]

Bill DunsmoreDepartment Manager

(018968) 26236 or(018968) 26247

[email protected]

Susan CottrellTransfusion Practitioner

[email protected]

Colin BruceQuality Manager

(018968) 26257 [email protected]

Medical advice is available at all times including out of hours by contacting Hospital switchboard and asking for the duty Haematology Consultant. With the exception of Andrology (semen) tests, the duty Haematologist will be happy to discuss our repertoire of tests and the interpretation of results.

1.4 Opening Hours

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Routine hours: Monday – Friday, 09.00 – 17.00

Public holidays: 09.00 – 17.00 (restricted staffing levels).

Christmas and New Year – out of hours service only.

1.5 Out of Hours Service

An emergency on call service is available outside normal opening hours.

A restricted repertoire of investigations is available during this period (see Appendix 1 for details).

If results are required immediately, the on-call BMS must be contacted before sending samples.

For requests with a lesser degree of urgency, the Department operates a batching system. Samples may be sent to the laboratory* without contacting the on-call BMS, these will be processed at the next batch time and the results made available within one hour.

17.00 to 20.00 weeknights: with the exception of blood tra, there is no need to notify the department, results will be available within 1 hour of sample receipt.

Batch TimesTime 07.30 11.00 14.00 17.00 23.00Weekday √ N/A N/A N/A √Sat/Sun √ √ √ √ √

Results will be made available for enquiry on the laboratory information system. Results will not be telephoned back to the requesting clinician except by prior agreement or where the results may indicate that the patient may need immediate attention.

Please remember that this service is staffed by a lone Biomedical Scientist. It would greatly assist the laboratory if requests sent during this period are restricted to those where results are required before the next period when the department is routinely open and also by correctly prioritising all work sent using the batch system if possible.

TO CONTACT THE ON CALL BMS, PAGE 6247 OR CALL SWITCHBOARD.

*Allowance must be made for sample viability when using batching system, see Appendix 1 for maximum sample stability times.

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1.6 Requesting Tests

All tests must be requested using the appropriate form and accompanied by the correct sample. Where forms or documentation other than the standard Haematology or Transfusion are required this is indicated in the relevant section of this handbook.

Mandatory patient ID requirements for sample and form may be found at the beginning of each section below.

Sample type for each investigation may be found in Appendix 1.

Where additional tests are required it may be possible to add these to a request already received. In all cases please telephone the department to discuss your requirements.

1.7 Specimen Collection

Routine samples will be collected and delivered to the laboratory by porters at the following times within Borders General:

9:30 to 10:30 Sample collections and deliver Lab reports11:15 to 11:45 Sample collections only12:30 to 13:30 Sample collections and deliver Lab reports*15:15 to 16:15 Sample collections only

Saturday, Sunday and Public Holiday: No routine collection

*Report delivery to medical wards only

Collection times by courier service for health centres and community hospitals may be found on the NHS Borders Intranet.

Samples for referral to external laboratories must arrive before 12:00 for same day dispatch.

1.8 Inoculation Risk Samples

All specimens from patients identified or suspected of having certain blood borne viruses or other infectious diseases and presenting a potential inoculation risk must be clearly identified. Note the following:

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Samples must be double bagged. Place sample in a “Biohazard” bag and seal this in the sample bag attached to the request form.

Tick the “Inoculation (BBV) Risk” box on the request form.

The department does not normally provide a full range of investigations for patients in this category. Please call the laboratory if you need clarification.

1.9 Reports

Printed reports will by delivered to BGH locations at the following times:

09.30 – 10.3012.30 – 13.30 (medical wards only)

Reports for surgeries and health centres will be delivered by courier.

Results may be viewed electronically on either SciStore or the laboratory web based enquiry system. If you require a logon for web enquiry please contact the IT help desk.

Return to contents page

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2 HAEMATOLOGY

See Appendix 1 for information on available investigations including sample type.

All specimen labels and request forms must have the following identifiers:

SurnameForenameCHI(Date of Birth may be used in place of CHI for selected groups of patients where CHI is not obtainable)

Addressograph labels are permitted on request forms. Small pre-printed patient ID labels may be used on sample tubes but tube contents must not be obscured and label must be wrapped carefully round the tube with no wrinkling or projections. On ESR tubes the label MUST be attached over the existing label at the base of the tube.

In addition the following information should be present on the request form:

Patient locationConsultant/GPDate and time of sampleRelevant clinical informationSignature of requestor

The department may reject requests where information is missing or incorrect.

2.1 General Haematology

2.1.1 The Full Blood Count

Our current FBC analysers report 14 parameters including an automated differential WBC.

New cases with the following parameters will be telephoned:

Hb <8.0 g/dl (<80g/L)WBC >25.0 x109/LNeutrophils <1.0 x109/LPlatelets <50 x109/L

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2.1.2 Blood Film

Blood film examination may be requested by clinical staff but is more often added by the laboratory in response to FBC or other results or to clinical details given. This department largely follows the International Society for Laboratory Haematology Consensus Guidelines on review of automated results.

A manual differential WBC may also be performed if the blood film appearance suggests that the automated count may be inaccurate.

2.1.3 Reticulocytes

May be requested by clinical staff or added by laboratory staff as required.

2.1.4 Glandular Fever (Infectious Mononucleosis) Screen

May be requested by clinical staff or may be added in response to FBC results or blood film appearances. A blood film will be examined for all GFST requests.

2.1.5 ESR

Sample tubes for ESR must not be under filled. Correct fill level is within 15 mm of the top of the narrow section of the tube before it begins to widen under the cap.

When using pre-printed labels on these tubes please ensure that they are attached over the existing label at the base of the tube.

For paediatric patients please send a 1.2 ml EDTA (red top) tube in addition to tube for FBC (if required).

2.1.6 Malaria and Other Blood Borne Parasites

Please contact the laboratory before sending samples for these investigations. It is important to let us know about all of the areas in which the patient may have travelled however briefly.

Thick and thin films are examined and a sensitive immunological slide test performed.

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Positive samples will be sent to the Scottish reference centre for confirmation.

Note that it may be necessary to send repeat samples on successive days to fully exclude malaria.

2.1.7 Bone Marrow Aspiration and/or Trephine Biopsy

Please discuss with duty Consultant Haematologist.

2.2 Coagulation

Sample tubes, which are significantly under or overfilled, may give unreliable results on coagulation testing as it is important to maintain the correct ratio of blood to anti-coagulant.

Tubes that are under or overfilled by >10% will not be tested. If coagulation screen or anticoagulant control test is required on small child or adult where venepuncture is difficult, smaller volume tubes (1.4 ml) are available.

2.2.1 INR (Warfarin Control)

INR should only be used for monitoring oral anticoagulant therapy (OAT).

Samples will be tested up to 24 hours post draw.

Unexpected INR > 4.0 will be telephoned to requestor.

2.2.2 APTT (Ratio)

This test is used to monitor treatment with unfractionated heparin (UFH).

Target range for APTR is 1.5 – 2.5

Results out with the target range will be telephoned.

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2.2.3 Coagulation Screen

Coagulation screen is NOT a routine investigation and should only be requested if indicated.

Do NOT request Coag. Screen if patient on Warfarin.

Coagulation screen samples should reach the laboratory as soon as possible, within 4 hours post venepuncture as the APTT results will deteriorate after 4 hours. Samples from PRIMARY CARE are only accepted if time of venepuncture is indicated on request form and specimen bottle. Where no time is indicated or the time is greater than 4 hours but less than 24 hours Prothrombin Time and Fibrinogen only will be performed.

Coagulation screen comprises the following tests: Prothrombin Time (PT) Activated Partial Thromboplastin Time (APTT) and Fibrinogen.

If the PT or APTT is prolonged, the test will be repeated with a mix of 50:50 normal plasma. Failure of the mix test to correct to normal or near normal may indicate the presence of a coagulation inhibitor.

2.2.4 D-Dimer

D-Dimer is a useful investigation in different clinical settings.

a) The investigation of consumption coagulopathy (DIC). D-Dimer may be requested by clinical staff or may be added as a result of abnormalities apparent in the FBC and/or coagulation screen.

b) The exclusion of venous thromboembolism (VTE), DVT or PE. D-Dimer may be used to exclude VTE in patients in the low or intermediate risk category (score <2) according to the Wells scoring system. All requests for this investigation MUST be accompanied by a copy of the clinical risk assessment form. Copies of this form may be accessed and printed from the Haematology NHS Borders intranet page.

Please note that samples must be tested within 2 hours.

2.2.5 Thrombophilia Screen

Thrombophilia investigations are referred to an external laboratory.

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Please send all requests for thrombophilia investigations accompanied by the appropriate request form, which may be found on the Haematology page of NHS Borders intranet.

Samples MUST arrive in the laboratory within 2 hours of draw. Thrombophilia screen requests are NOT ACCEPTED from primary care, unless discussed with Consultant Haematologist. Testing should be avoided in the presence of:

Acute thrombosisPregnancy (and within 12 weeks post partum)Anticoagulant therapyOestrogen containing medicine

It is recommended that thrombophilia screening be performed at least 4 weeks after stopping anticoagulation.

In suspected recurrent VTE when lifelong anticoagulation may be indicated, it is appropriate to do a thrombophilia screen during the acute event prior to starting anticoagulant therapy. Abnormal results in those situations should be interpreted and monitored with care, in consultation with Haematologist.

To avoid unnecessary tests, the laboratory will save samples for thrombophilia requests for up to 7 days to permit the clinical team to establish a definite diagnosis. If a confirmed diagnosis of thromboembolism or acute arterial thrombosis is not communicated to the laboratory the samples will be discarded.

Tests offered for Thrombophilia Screens:

Screen 1: Protein C, Protein S, Antithrombin III, Factor 2 and 5 LeidenScreen 2: Lupus Anticoagulant and Anti Cardiolipin Antibodies

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CLINICAL DETAILS SPECIMEN REQUIREDSCREEN

1 2Obstetric Indications (Samples to be taken out-with pregnancy and more than 12 weeks postpartum) Recurrent ( ≥ 2) miscarriages

2 x 3 ml Sodium Citrate (Green)1 x 2.7 ml E.D.T.A. (Red)1 x 4.7 ml Serum-Gel (Brown)

√ √ Previous pre eclampsia √ √ Previous IUGR √ √ Previous unexplained stillbirth(s) √ √ Previous abruption placenta √ √General Indications Venous thromboembolism before the age of 60 years

2 x 3 ml Sodium Citrate (Green)1 x 2.7 ml E.D.T.A. (Red)1 x 4.7 ml Serum-Gel (Brown)

√ √ Recurrent venous thromboembolism or thrombophlebitis √ √ Venous thrombosis in an unusual site (e.g., mesenteric, axillary) √ √ Arterial thrombosis before 40 years, or 50 years without risk factors √ √ Unexplained prolonged activated partial thromboplastin time X √ Unexplained neonatal thrombosis 2 x 3 ml Sodium Citrate (Green)

1 x 2.7 ml E.D.T.A. (Red)√ X

Skin necrosis, particularly if on coumarins √ X Others – by special arrangement only, contact laboratory

Table 1 Indications for Thrombophilia Screening

2.2.6 Induction and Maintenance of Anticoagulation

Please see the document “Induction and Maintenance of Anticoagulation” on the Haematology page of NHS Borders intranet for advice and information on the use of intravenous and oral anticoagulant therapy.

2.3 Haematinics (Vitamin B12 & Folate)

See Clinical Chemistry Handbook


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3 ANDROLOGY (SEMEN ANALYSIS)

PLEASE NOTE THAT SEMEN ANALYSIS IS A RESULTS ONLY SERVICE AND THAT THE LABORATORY IS NOT IN A POSITION TO PROVIDE CLINICAL ADVICE RELATING TO THESE INVESTIGATIONS.

3.1 Infertility Investigation

Only sample containers issued from the Haematology laboratory may be used. It is known that some plastics are toxic to sperm and in recognition of this the laboratory quality assures all specimen containers used for semen analysis.

For all patients requiring investigation of suspected male infertility please contact the laboratory, which will issue a pack consisting of an approved container, instructions for collection of sample and request form. (See Haematology page of NHS Borders intranet for copies of instructions to patients).

It is important that the sample be delivered to the laboratory within 1 hour of collection and that it is kept at body temperature during transportation. It should be delivered to the Haematology laboratory by patient or relative. DO NOT SEND BY ROUTINE COURIER.

The sample container must be labelled as follows:

Full name (forename and surname)Date of BirthDate and time of collection.

The following parameters will be reported, reference range in brackets.

Semen Volume (1 - 6 ml)Sperm Motility (> 50%)Sperm Count (>20 x106/ml)

The presence of significant numbers of RBCs or WBCs will be reported.

Gross abnormalities of sperm morphology will also be reported.

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3.2 Post Vasectomy Screening

The patient will be provided with two packs containing request forms, specimen containers and instructions for collecting the sample when discharged from the hospital following surgery. (See Haematology page of NHS Borders intranet for copies of instructions to patients).

Samples must be labelled with full name (forename and surname), date of birth and date and time of sample collection. Forms must be completed in full and signed and dated by the patient. Samples will be rejected if not properly labelled or if the form is not completed correctly.

Only sample containers issued from the Haematology laboratory may be used for semen analysis. Samples received in any other containers will be rejected.

The first sample should be sent no earlier than 4 months post vasectomy and after at least 25 ejaculations. A second sample should be sent 2-4 weeks after the first. Any further samples required should be sent at least 2 weeks apart.

Initial samples may be sent by courier but must arrive in the laboratory within 6 hours.

To enable the surgeon to give clearance to withdraw from alternative method of contraception after vasectomy, two consecutive azoospermic samples are required.

A proportion of patients will shed small numbers of sperm for long periods after vasectomy, sometimes intermittently. If two consecutive azoospermic samples are not obtained a further sample (taken at least 28 weeks post vasectomy) will be requested for further testing including, if required, a sperm Vitality Test.

This test will ascertain whether sperm present are alive or dead. The laboratory will provide a pack for this investigation. This pack consists of a sample container, request form and special instructions for collection.

This sample must be delivered to the laboratory within 1 hour of collection.

The following will be reported:Delay to examinationSemen volumeDirect microscopy (examination of a portion of the sample)

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Complete microscopy (examination of the complete sample)Sperm vitality (only on 3rd sample if required)Guidance on Interpretation

Sample 1 Sample 2 Sample 31 OutcomeNo Sperm No Sperm Not Required ClearanceSperm seen No Sperm No Sperm ClearanceNo Sperm Sperm seen Sperm seen2 Special clearanceSperm seen Sperm seen No Sperm Further test3

Table 2 Interpretation of Screening Results

1Sample for vitality screening at >28 weeks post vasectomy.2Sperm count is <10,000/ml and none are live.

3A further vitality screen sample, 2-4 weeks after the 3rd, may be examined in order to allow two consecutive azoospermic results and therefore ordinary clearance. If sperm are present in this sample special clearance may be given if the above criteria are met. Contact the laboratory if this is required.


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4 BLOOD TRANSFUSION

See also the following NHS Borders Policies:

Transfusion Policy

Protocol for the Use of Irradiated and CMV Negative Blood and Blood Products

Emergency Blood Management Plan

Major Haemorrhage Protocol

4.1 Mandatory Requirements

ALL TRANSFUSION RELATED ERRORS AND INCIDENTS MUST BE REPORTED TO THE LABORATORY PROMPTLY. IT IS A MANDATORY REQUIREMENT THAT THE HAEMOVIGILANCE TEAM REPORT ALL SERIOUS ADVERSE REACTIONS AND EVENTS TO THE MHRA SABRE SCHEME.

4.1.1 Training

It is now a legal requirement that ALL staff involved in the transfusion process are fully trained in the procedures appropriate to their role. This applies to staff involved in processes from initial requesting and sample taking through testing, issue and collection of products to final checks and administration. These skills must be maintained by regular update and competency assessment.

For details of training and assessment please contact Transfusion Practitioner.

4.1.2 Minimum Data Set

All documentation relating to blood transfusion including sample label MUST show the following identifiers:

SurnameForenameDate of BirthCHI number* Gender

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*Patients for whom a normal CHI number is not available, for example individuals not normally resident in Scotland, will be issued with a temporary CHI number by the PMS system.

The laboratory will reject requests, samples or other documentation where any of the above identifiers are missing or incorrect. Addressograph labels are not allowed.

Where unambiguous patient identification is unavailable e.g. unconscious patient, then a temporary CHI (issued by PMS) number must be used on form and sample along with “Unknown” for Surname and Forename. Gender must be included.

Request form must be signed by the medical officer requesting the transfusion and counter signed by the person drawing the sample if this is different.

Person drawing the sample must sign sample tube.

4.2 Provision of Blood and Blood Components

4.2.1 Group and Save Serum

In all cases where it is possible that a transfusion may be required a Group and Save request should be sent. If significant antibodies were not detected (and the patient has no previous record of such antibodies – PLEASE CHECK RECORDS BEFORE SENDING REQUEST) then red blood cells can be made available quickly if required.

If antibodies are detected then compatible red cells will be made available to avoid delay should the need for transfusion arise.

Group and Save samples will be retained for 7 days and may be used to issue red cells according to timings shown in Table 3 below.

Table 3. Timing of sample collection in relation to previous transfusionsPatient Transfused* Within Previous Sample To Be Taken Within3 to 14 days 24 h before transfusion15 to 28 days 72 h before transfusion29 days to 3 months 1 week before transfusion*Transfusion of any material which may contain RBC antigens i.e. red cells, platelets, FFP, cryoprecipitate.

Where patients are being repeatedly transfused, i.e. daily, a fresh sample should be sent and screened for irregular antibodies every 72

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hours. This sample may also be used for subsequent compatibility testing.

During pregnancy, samples for pre -transfusion testing should NEVER be taken more than 7 days before date of transfusion.

If patient has been transfused more recently or you are not sure, please contact the laboratory.

By arrangement with the laboratory, patients attending pre-assessment clinics prior to routine surgery may have samples tested and frozen for up to 2 month prior to surgery. This facility is dependent upon meeting the requirements set out in Table 3 above.

4.2.2 Issue of Red Cell Concentrate

Where transfusion is likely or for surgical procedures identified in the Maximum Surgical Blood Ordering Schedule (see below) the requested number of units will be made available at the date and time specified on the request form. Note the following:

WHEN REQUESTING BLOOD, PLEASE CHECK PATIENT RECORDS FOR SPECIAL REQUIREMENTS E.G. IRRADIATED OR CMV NEGATIVE.

Blood units will only be kept for 24 hours post date and time required. If transfusion is delayed please contact the laboratory.

Units may be collected from the blood issue refrigerator accessed from BGH second floor corridor opposite theatre suite. This area is access controlled; only staff with appropriate privileges may gain entry.

Staff collecting blood must bring a blood collection slip completed by the requesting clinical staff.

Following completion of the transfusion, the blue section of the tag attached to the pack MUST be completed and returned to the laboratory as soon as possible.

Emergency Issue

See also Major Haemorrhage and Major Incident Protocols

For extreme emergencies where blood is required immediately, 2 units of group O Rh (D) negative red cell concentrate are available in the blood issue fridge. Please contact the laboratory as soon as possible to

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alert staff to the usage of these units and to discuss on-going transfusion support.

Where requirement is less extreme (and where a sample has been sent) group specific blood can be supplied in 10-15 minutes and fully compatibility tested in 40-45 minutes.

Neo-natal Transfusion

Neonates (less than 4 months) rarely make antibodies in response to blood transfusion but may have red cell antibodies in their plasma that have been passively acquired from the mother. At the time of sending the first request, if possible, a maternal sample should also be sent. If a maternal sample is sent (7.5 ml red top TRANSFUSION) we require only 0.5 mls EDTA blood from the baby. If no maternal sample is available then we need a larger volume from the baby (1-1.5 mls). For subsequent requests maternal blood is not required and it may be possible to provide blood without further samples being sent from the baby (check with the lab).

A Pedipack system is available for top-up transfusion in neonates who are likely to require more than one transfusion in a 4-week period. These units are divided into 4 aliquots each of around 60-70 mls and these aliquots are available for sequential transfusion in one infant thus reducing donor exposure. Please note that as Pedipacks are no longer stocked on site at Borders General and have to be ordered from SNBTS the Transfusion Department will require at least 4 hours notice if a unit is required.

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Maximum Surgical Blood Ordering Schedule (MSBOS)General SurgerySimple Mastectomy Group and SaveCholecystectomy Group and SaveT.U.R.P. Group and SaveRadical Mastectomy 2 UnitsThyroidectomy Group and SaveLaparotomy Group and SaveGastrectomy 3 UnitsSplenectomy 3 UnitsNephrectomy 3 UnitsColectomy/Hemi Colectomy 3 UnitsAnterior Resection 2 UnitsA - P Resection 2 Units

Orthopaedic SurgeryLaminectomy Group and SaveFracture neck of femur Group and SaveKnee Replacement Group and SaveHip Replacement Group and SaveOsteotomy 2 UnitsSpinal Fusion 2 UnitsAbove Knee Amputation 2 UnitsFracture Shaft of Femur 2 UnitsRevision of Hip 2 UnitsTrauma As requested

Obstetrics and GynaecologyThreatened Abortion Group and SaveCone Biopsy Group and SavePelvic Floor Repair Group and SaveHysterectomy Group and SaveCaesarean Section Group and SaveAnte-Partum Haemorrhage 2 UnitsEctopic Pregnancy Group and SavePlacenta Praevia 2 Units (Fresh sample every 7 days)

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4.2.3 Other Blood Components

Fresh Frozen Plasma and Cryoprecipitate

FFP and Cryoprecipitate require 20 –30 minutes thawing time. Issue of these products requires approval of the duty Consultant Haematology.

Platelet Concentrate

Blood bank routinely stocks one treatment unit of platelet concentrate which may be issued following approval of the duty Consultant Haematology.

4.3 Transfusion Reaction

In the event of an acute transfusion reaction, stop the transfusion immediately and report the incident to the Blood Bank

For full information on assessment, investigation and management of suspected reaction to blood or blood components see NHS Borders Transfusion Policy document.

All requests for investigation of suspected reactions must be made on the NHS Borders Transfusion Reaction Investigation Form available on NHS Borders Intranet Blood Transfusion page.

List of Components and Products Available

Red Cell Concentrate (includingCMV and/or irradiated units)RCC Split Pack (Pedipack) – Notice requiredFresh Frozen PlasmaFFP Methylene Blue treatedCryoprecipitatePlatelet concentrate1

Four Factor Concentrate (Beriplex)Recombinant FVIIa (Novoseven)Anti D immunoglobulin 250 iuAnti D immunoglobulin 500 iuAnti D immunoglobulin 1500 iuAnti Tetanus immunoglobulinAnti Zoster immunoglobulinAnti Hepatitis B immunoglobulin

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4.4 Antenatal Screening and Rhesus Prevention

Note that minimum data set requirements described in section 4.1.2 also apply to antenatal samples

Antenatal Screening

The following for sampling during pregnancy are recommended, to ensure that no clinically important antibody is overlooked, and that in the event of a blood transfusion being required at time of delivery, appropriate blood can be available.

Rh (D) Positive Rh (D) Negative

Booking X X28 Weeks X X40 Weeks (Term) X

If at any time a significant antibody is detected further samples will be requested for confirmation studies and antibody quantification, and a sample from partner. The appropriate timing of these follow up samples will be given on the report form.

Rhesus Immunisation Prevention

All Rh (D) Negative women over 12 weeks gestation with no detectable immune Anti-D antibody who experience a potentially sensitising event must be given Anti-D immunoglobulin.

Up to 20 weeks gestation this will be 250 iu after this time 500 iu is the appropriate dose.

In addition, after 20 weeks a sample should be sent for Feto-maternal haemorrhage estimation (Kleihauer) to establish if further Anti-D is required.

In all cases a sample for grouping and antibody screen must be sent.

All Rh (D) negative women with no detectable immune Anti-D antibody are eligible for anti-D prophylaxis. A single dose of 1500 iu will be sent to the requesting health centre with the report on the 28 week screening sample.

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At term maternal group and screening and Kleihauer samples, along with a sample of cord blood must be sent. Anti-D immunoglobulin will be issued as appropriate.

4.5 Other Investigations

Cold Agglutinins

Contact Transfusion department.

Cryoglobulins

Contact Transfusion department.


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Appendix 1 – Tests and Requests

Sample Tube TypesDescription Tests

E2.7 Red top 2.7 ml EDTA FBC, Blood film, Retics, DAT, Malaria screen, GFST, Sickle screen, Genetic studies, Haemoglobinopathy screen, Factor II and V Leiden, Kleihauer

E1.2 Red top 1.2 ml EDTA As above –use instead of E2.7 for paediatric patients or restricted venous access.Blood group and DAT on newborn babies.

E7.5 Red top 7.5 ml EDTA Blood group and screen, Antenatal serology, pre transfusion testing (X-match), Cold agglutinins, Cord group.

C3.0 Green top 3.0 ml Citrate INR, Coag screen, D-Dimer, APTT (Ratio), Factor Assay, Thrombophilia Screen.C1.4 Green top 1.4 ml Citrate As above –use instead of C3.0 for paediatric patients or restricted venous access.SG5.0 Brown top 4.7 ml Serum Gel Anticardiolipin antibodies.ESR Purple top 3.5 ml ESR ESR.LH5.5 Orange top 5.5ml Lithium Heparin Osmotic fragility.AND Orange top wide necked container Infertility screen, Post vasectomy screen.W10.0 White top 10.0ml Plain tube Pre transfusion testing (Further investigations/problem patients), Neutrophil

antibodies, Cryoglobulins, HIT screen.W20.0 White top Universal container Urinary haemosiderin, other fluids.


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List of Tests/Requests

TestRequestItem

TubeType1

Stability Hrs

ReferenceRange*

OOHY/N

Turnaround Time2 ReferralLaboratory Routine Emerg

Haemoglobin FBC E2.7 72 M 13.0 – 18.0 g/dl (130 – 180 g/L)F 11.5 – 16.5 g/dl (115 – 165 g/L)

Y 24h 1h N/a

White Cell Count FBC E2.7 24 4.0 – 11.0 x109/L Y 24h 1h N/a

Platelet Count FBC E2.7 24 150 - 400 x109/L Y 24h 1h N/a

Red Cell Count FBC E2.7 24 M 4.5 – 6.5 x1012/LF 3.8 – 5.8 x1012/L

Y 24h 1h N/a

Haematocrit FBC E2.7 24 M 0.40 – 0.54F 0.36 – 0.47

Y 24h 1h N/a

Mean Cell Volume FBC E2.7 24 80 – 100 fl Y 24h 1h N/a

Mean Cell Haemoglobin FBC E2.7 24 27 – 32 pg Y 24h 1h N/a

Mean Cell Haemoglobin Concentration

FBC E2.7 24 32 – 36 g/dL (320 – 360 g/L) Y 24h 1h N/a

Neutrophils FBC E2.7 24 2.0 – 7.5 x109/L Y 24h 1h N/a

Lymphocytes FBC E2.7 24 1.0 – 4.0 x109/L Y 24h 1h N/a

Monocytes FBC E2.7 24 0.2 – 1.0 x109/L Y 24h 1h N/a

Eosinophils FBC E2.7 24 0.0 – 0.4 x109/L Y 24h 1h N/a

Basophils FBC E2.7 24 0.0 – 0.2 x109/L Y 24h 1h N/a

INR INR C3.0 24 2.0 – 4.0 (therapeutic range) Y 24h 1h N/a

Prothrombin Time PT C3.0 24 9.4 – 12.5 seconds Y 24h 1h N/a

Activated partial thromboplastin time

APTT C3.0 4 25.1 – 36.5 seconds Y 24h 1h N/a

Fibrinogen FIBC C3.0 24 2.4 – 5.0 g/L Y 24h 1h N/a

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TestRequestItem

TubeType1

Stability Hrs

ReferenceRange*

OOHY/N


D Dimer (for exclusion of VTE)

DDVT C3.0 2 <230ng/ml – negative>230ng/ml – positive

Y 24h 1h N/a

D Dimer (? DIC) DDIC C3.0 2 0 – 243ng/ml Y 24h 1h N/a

Thrombin Time TT C3.0 4 10.3 – 16.6 seconds Y 24h 1h N/a

Anti Xa LMWH C3.0 4 Dependant on LMWH used N 2 wks N/a Coagulation Lab, Haematology, NRIE

Blood Film FILM E2.7 24 N/a Y 72h 1h N/a

Bone Marrow Examination MAR N/a N/a N/a N 72h N/a N/a

Bone Marrow Trephine TREP N/a N/a N/a N 3 wks N/a Pathology Laboratory, NRIE

Blood borne parasites (e.g. malaria)

PAR E2.7 24 N/a Y 24h 2h N/a

Retics RET E2.7 24 50 - 100 x109/L N 24h N/a N/aESR ESR ESR 24 M 0 – 30 mm/hour

F 0 - 35 mm/hourY 24h 2h N/a

Infectious Mononucleosis Screen

GFST E2.7 24 N/a Y 24h 1h N/a

Sickle Screen SICK E2.7 24 N/a Y 24h 1h N/a

Infertility Screen INF AND 1 Volume - >2.0mlMotility - >50%Count - >20 x106/ml

N 24h N/a N/a

Vasectomy Screen VAS2 AND 6 N/a N 24h N/a N/aThrombophilia tests THRO E2.7

C3.0 x3 SG5.0

4 Printed with result on referral laboratory report.

N 4 wks N/a Coagulation Lab, Haematology, NRIE

Lupus screen LUP C3.0 x2SG5.0

4 Printed with result on referral laboratory report

N 4 wks N/a Coagulation Lab, Haematology, NRIE

Anticardiolipin Antibodies ACAB SG5.0 24 Printed with result on referral N 4 wks N/a Coagulation Lab,

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TestRequestItem

TubeType1

Stability Hrs

ReferenceRange*

OOHY/N


laboratory report Haematology, NRIEFactor II and V Leiden FVL E2.7 72 N/a N 4 wks N/a Coagulation Lab,

Haematology, NRIECoagulation factor assays FACT C3.0 4 Printed with result on referral

laboratory reportN 4 wks N/a Coagulation Lab,

Haematology, NRIEvon Willebrand studies VW C3.0 4 Printed with result on referral

laboratory reportN 4 wks N/a Coagulation Lab,

Haematology, NRIEImmunophenotyping MARK E2.7 24 N/a N 3 wks N/a Immunology, WGH

Cytogenetics CHROM 24 N/a N 4 wks N/a Immunology, WGH

Haemoglobinopathy screen (must include ferritin request)

HBOP E2.7SG5.0

72 Printed with result on referral laboratory report

N 4 wks N/a Haematology, NRIE

Plasma viscosity PV E2.7 72 Printed with result on referral laboratory report

N 2 wks N/a Haematology, KVH

JAK2 JAK2 E2.7 48 N/a N 4 wks N/a MolecularHaematology, NRIE

Haptoglobin HAPT SG5.0 48 Printed with result on referral laboratory report


PNH SEND E2.7 24 N/a N 4 wks N/a Haematology, WGH

Glucose 6-P Dehydrogenase

G6PD E2.7 24 Printed with result on referral laboratory report


Neutrophil antibodies SEND E7.5,W10.0

24 N/a N 4 wks N/a SNBTS, Aberdeen

B and T cell subsets SEND E2.7 24 N/a N 4 wks N/a RHSC, Edinburgh

Urinary Haemosiderin UH U20.0 24 N/a N 72 h N/a N/a

Osmotic Fragility3 FRAG LH5.5 6 MCF (50% lysis) 4.0 – 4.45 N 72 h N/a N/a

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TestRequestItem

TubeType1

Stability Hrs

ReferenceRange*

OOHY/N


Heparin Induced Thrombocytopenia Screen 3

HIT W10.0 24 N/a N 4 wks N/a SNBTS, NRIE

Blood Group and Screen GS E7.5 72 N/a Y 24 h 1 h N/a

Direct agglutination test DAT E2.7 24 N/a Y 24 h 1 h N/a

Rhesus Program RHP E7.5 x2E2.7 x2

72 N/a Y 72 h 4 h N/a

Kliehauer Test FC E2.7 24 N/a Y 24 h 1 h N/a

Cold agglutinins 4 CLDAG E7.5 1 N/a N 48h N/a N/a

Cryoglobulins 4 CRYO W10.0 1 N/a N 48h N/a N/a

HLA typing HLA E7.5 24 N/a N 4 wks N/a SNBTS, NRIE

Platelet antibodies PLAB W10.0E7.5

24 N/a N 4 wks N/a SNBTS, NRIE

*Normal adult ranges, ranges appropriate for patient age and gender will be printed with report.

1 Or paediatric equivalent if available.

2 Time from receipt of sample to availability of result (electronic or hard copy)

3 Please include a vial of the patients’ heparin.

4 By prior arrangement with the laboratory.


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Appendix 2 – List of External Referral Laboratories.

External Laboratory Tests Referred Coagulation Lab, Haematology, New Royal InfirmaryEdinburgh

Thrombophilia tests, Lupus screen, Anticardiolipin Antibodies, Factor II and V Leiden, Coagulation factor assays, von Willebrand studies

Immunophenotyping DepartmentHaematology Laboratory Western General HospitalEdinburgh

Immunophenotyping

Cytogenetics LaboratoryMicrobiology BuildingWestern General HospitalEdinburgh

Cytogenetics

Haematology LaboratoryNew Royal InfirmaryEdinburgh

Haemoglobinopathy screen, Haptoglobin, Glucose 6-P Dehydrogenase

Haematology LaboratoryVictoria HospitalKikcaldy

Plasma viscosity

Molecular Haematology New Royal InfirmaryEdinburgh

JAK2

Haematology LaboratoryWestern General HospitalEdinburgh

PNH

Scottish National Blood Transfusion Service,Aberdeen

Neutrophil antibodies

Royal Hospital for Sick ChildrenEdinburgh

B and T cell subsets

Scottish National Blood Transfusion Service, New Royal InfirmaryEdinburgh

Confirmation of antibodies, resolution of complex serology and issue of blood/products for patients with complex requirements.Heparin Induced Thrombocytopenia Screen, HLA Typing, Platelet antibodies


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department of haematology and blood ......haematology and blood transfusion laboratory user handbook...

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