blood components what do you need to know?
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BLOOD COMPONENTS WHAT DO YOU NEED TO KNOW?. Janine Carnell Transfusion Nurse Consultant Eastern Health. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, - PowerPoint PPT PresentationTRANSCRIPT
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