BLOOD TRANSFUSIONBLOOD TRANSFUSION

MAXINE BOYDMAXINE BOYD

HOSPITAL TRANSFUSION HOSPITAL TRANSFUSION PRACTITIONERPRACTITIONER

HOSPITAL HOSPITAL TRANSFUSION TEAMTRANSFUSION TEAM CONSULTANT HAEMATOLOGIST – CONSULTANT HAEMATOLOGIST –

LEAD FOR TRANSFUSION MEDICINELEAD FOR TRANSFUSION MEDICINE BLOOD BANK MANAGERBLOOD BANK MANAGER HOSPITAL TRANSFUSION HOSPITAL TRANSFUSION

PRACTITIONERPRACTITIONER CHAIR HOSPITAL TRANSFUSION CHAIR HOSPITAL TRANSFUSION

COMMITTEECOMMITTEE PATHOLOGY QUALITY MANAGERPATHOLOGY QUALITY MANAGER

COST OF BLOOD COST OF BLOOD PRODUCTSPRODUCTS Packed Red Cells = £136.05Packed Red Cells = £136.05 Fresh Frozen Plasma = £35.37Fresh Frozen Plasma = £35.37 Platelets = £226.18Platelets = £226.18 Cryoprecipitate = £221.38Cryoprecipitate = £221.38 Albumin = £20Albumin = £20

Special requirements – additional Special requirements – additional costcost

Emergency Blood Emergency Blood Management PlanManagement Plan

July 2004 DoH issued summary version of July 2004 DoH issued summary version of the ‘National Contingency Plan for Blood the ‘National Contingency Plan for Blood Shortages’Shortages’

Each Trust expected to have their own EBMP Each Trust expected to have their own EBMP based on this guidancebased on this guidance

Based on traffic light system –Trust running Based on traffic light system –Trust running on green under normal circumstances on green under normal circumstances

In cases of shortage – some elective ops. will In cases of shortage – some elective ops. will be cancelled – patients with greatest clinical be cancelled – patients with greatest clinical need are prioritisedneed are prioritised

Blood ConservationBlood Conservation

Adhere to guidelines and policy Adhere to guidelines and policy including MSBOSincluding MSBOS

Autologous transfusionAutologous transfusion- intra-operative cell salvage- intra-operative cell salvage- post operative cell salvage- post operative cell salvage

Pre-operative assessmentPre-operative assessment Education and TrainingEducation and Training Pharmaceutical alternatives e.g Pharmaceutical alternatives e.g

erythropoietinerythropoietin

RED CELL RED CELL TRANSFUSION TRANSFUSION

TRIGGERSTRIGGERSGuidelines for the clinical use of red Guidelines for the clinical use of red

cell transfusions (BCSH 2001)cell transfusions (BCSH 2001)

Hb > 10g/dl – Transfusion not Hb > 10g/dl – Transfusion not indicatedindicated

Hb > 7-10g/dl – Transfuse only if Hb > 7-10g/dl – Transfuse only if clinically indicatedclinically indicated

Hb < 7g/dl – Transfusion Hb < 7g/dl – Transfusion generally generally indicated indicated

Red Cell Transfusion Red Cell Transfusion Triggers cont…..Triggers cont…..

Critical Care:Critical Care:transfuse to maintain Hb >7 g/dltransfuse to maintain Hb >7 g/dl

Post-chemotherapy:Post-chemotherapy:transfusion threshold of 8 or 9 g/dltransfusion threshold of 8 or 9 g/dl

Radiotherapy:Radiotherapy:transfuse to maintain Hb above 10 g/dltransfuse to maintain Hb above 10 g/dl

Chronic anaemia:Chronic anaemia:Transfuse to maintain Hb just above lowest Transfuse to maintain Hb just above lowest conc. not associated with symptoms of conc. not associated with symptoms of anaemia (usually patients asymptomatic with anaemia (usually patients asymptomatic with Hb >8 g/dl)Hb >8 g/dl)

Indications for Indications for Transfusion Platelets Transfusion Platelets

(BCSH, 2004)(BCSH, 2004) To prevent spontaneous bleeding To prevent spontaneous bleeding

when the platelet count <10 x 10when the platelet count <10 x 1099/l/l To prevent spontaneous bleeding To prevent spontaneous bleeding

when the platelet count <20 x when the platelet count <20 x 101099/l in the presence of additional /l in the presence of additional risk factors such as sepsis or risk factors such as sepsis or haemostatic abnormalitieshaemostatic abnormalities

To prevent bleeding associated To prevent bleeding associated with invasive procedureswith invasive procedures

Platelets cont…Platelets cont…

Massive blood transfusionMassive blood transfusion Bleeding, not surgically correctable Bleeding, not surgically correctable

and associated acquired platelet and associated acquired platelet dysfunctiondysfunction

Acute disseminated intravascular Acute disseminated intravascular coagulation (DIC) in the presence of coagulation (DIC) in the presence of bleeding and thrombocytopeniableeding and thrombocytopenia

Inherited platelet dysfunction with Inherited platelet dysfunction with bleeding or as prophylaxis before bleeding or as prophylaxis before surgerysurgery

Indications for Indications for Transfusion Fresh Frozen Transfusion Fresh Frozen

Plasma (BCSH 2004)Plasma (BCSH 2004) Replacement of single coagulation factor Replacement of single coagulation factor

deficiencies where a specific or combined deficiencies where a specific or combined factor concentrate is unavailablefactor concentrate is unavailable

Immediate reversal of warfarin effect Immediate reversal of warfarin effect in in the presence of life threatening bleedingthe presence of life threatening bleeding

Acute DIC in the presence of bleeding and Acute DIC in the presence of bleeding and abnormal coagulation resultsabnormal coagulation results

TTP in conjunction with plasma exchangeTTP in conjunction with plasma exchange Massive transfusion and surgical bleedingMassive transfusion and surgical bleeding

Indications for Indications for Transfusion Transfusion

Cryoprecipitate (BCSH, Cryoprecipitate (BCSH, 2004)2004)

AcuteAcute DIC where there is DIC where there is bleeding and fibrinogen level bleeding and fibrinogen level <1g/l<1g/l

Bleeding associated with Bleeding associated with thrombolytic therapy causing thrombolytic therapy causing hypofibrinogenaemiahypofibrinogenaemia

Hypofibrinogenaemia 2Hypofibrinogenaemia 2o o to to massive transfusionmassive transfusion

SPECIAL SPECIAL REQUIREMENTSREQUIREMENTS

IrradiatedIrradiated CMV negativeCMV negative Antigen negativeAntigen negative Washed Washed

Massive blood lossMassive blood loss

Aim of treatment: Aim of treatment:

- restore adequate blood volume - restore adequate blood volume

- maintain blood composition within safe - maintain blood composition within safe limitslimits

Stem bleeding surgicallyStem bleeding surgically

Use RBC’s, crystalloids / colloids to maintain Use RBC’s, crystalloids / colloids to maintain

BP / BV / HB >7g/dl BP / BV / HB >7g/dl

Massive Transfusion Massive Transfusion GuidelinesGuidelines

Acute blood loss – Guidelines for clinical use of Acute blood loss – Guidelines for clinical use of red cell transfusions (BCSH, 2001)red cell transfusions (BCSH, 2001)

Maintain circulating blood volume and Hb conc. >7g/dl in Maintain circulating blood volume and Hb conc. >7g/dl in otherwise fit patients & >9g/dl in older patients and those otherwise fit patients & >9g/dl in older patients and those with known cardiovascular diseasewith known cardiovascular disease

15-30% loss of blood volume (800-1500ml in an 15-30% loss of blood volume (800-1500ml in an adult):adult): transfuse crystalloids or synthetic colloids. Red transfuse crystalloids or synthetic colloids. Red cell transfusion is unlikely to be necessary.cell transfusion is unlikely to be necessary.

30-40% loss of blood volume (1500-2000ml in 30-40% loss of blood volume (1500-2000ml in an adult):an adult): rapid volume replacement is required with rapid volume replacement is required with crystalloids or synthetic colloids. Red cell transfusion will crystalloids or synthetic colloids. Red cell transfusion will probably be required toprobably be required tomaintain recommended Hb levels.maintain recommended Hb levels.

>40% loss of blood volume (>2000ml in an >40% loss of blood volume (>2000ml in an adult):adult): rapid volume replacement including red cell transfusion is rapid volume replacement including red cell transfusion is required.required.

Massive bleed Massive bleed procedureprocedure

Administer crystalloids / colloids until 1500ml Administer crystalloids / colloids until 1500ml loss of bloodloss of blood

Inform blood bank – degree of urgencyInform blood bank – degree of urgency

Samples collected for crossmatching, FBC, Samples collected for crossmatching, FBC, clotting, biochemistry. clotting, biochemistry.

2 x O Rh (D) negative units available - 2 x O Rh (D) negative units available - always inform blood bankalways inform blood bank

ABO Rh (D) group specific blood available ABO Rh (D) group specific blood available 10 mins. after sample arrives in blood 10 mins. after sample arrives in blood bank bank Medical staff must accept full Medical staff must accept full responsibility for administration of responsibility for administration of un-crossmatched bloodun-crossmatched bloodX-matched blood available after 40 mins.X-matched blood available after 40 mins.

Monitor FBC & clotting (inc. fibrinogen) to Monitor FBC & clotting (inc. fibrinogen) to guide blood component therapy guide blood component therapy

Taking Blood SamplesTaking Blood Samples

Only 1 patient at a time.Only 1 patient at a time. Identify the correct patient.Identify the correct patient. Confirm identification.Confirm identification.

– First name.First name.– Surname.Surname.– Address.Address.– Date of birth.Date of birth.

Check the wristband with the Check the wristband with the request form.request form.

Taking Blood SamplesTaking Blood Samples

Take the blood.Take the blood. At the bedside label the sample bottle,using At the bedside label the sample bottle,using

inkink– First nameFirst name– SurnameSurname– DOBDOB– Hospital Registration Number (or casualty Hospital Registration Number (or casualty

no.)no.)– DateDate– Signature of person taking bloodSignature of person taking blood

DO NOT!DO NOT!

Do not ask someone else to label the Do not ask someone else to label the sample.sample.

Do not label the sample prior to Do not label the sample prior to phlebotomy.phlebotomy.

Do not leave the bedside until you Do not leave the bedside until you have labelled the sample tube.have labelled the sample tube.

Do not use pre-printed labels to label Do not use pre-printed labels to label the sample tube.the sample tube.

Do not use the form details to label the Do not use the form details to label the sample tube.sample tube.

PRESCRIBINGPRESCRIBING

Prescription chart must contain:Prescription chart must contain:

- Full patient identification details i.e- Full patient identification details i.e

full name, date of birth, hospital full name, date of birth, hospital number number

Must specify:Must specify:

- Blood product to be administered, - Blood product to be administered, quantity, duration and special quantity, duration and special

instructions instructions

Serious Adverse Serious Adverse ReactionsReactions

ACTIONACTION Stop transfusion immediatelyStop transfusion immediately Take down blood product / giving Take down blood product / giving

setset Maintain IV access with infusion of Maintain IV access with infusion of

0.9% sodium chloride0.9% sodium chloride Treat patientTreat patient Inform Blood Bank Inform Blood Bank

Adverse reaction Adverse reaction cont…cont…

InvestigationInvestigation

Send to Blood Bank:Send to Blood Bank: The unit of bloodThe unit of blood Samples stated on transfusion Samples stated on transfusion

reaction formreaction form Complete adverse reaction report Complete adverse reaction report

(from blood bank)(from blood bank)

Incident ReportingIncident Reporting– An incident form will be completed for all An incident form will be completed for all

adverse reactions and for any events adverse reactions and for any events which delay the patients treatment.which delay the patients treatment.

– An incident form will be completed for An incident form will be completed for any practice that contravenes this policy.any practice that contravenes this policy.

– All incidents will be graded and All incidents will be graded and investigated in line with the Trust investigated in line with the Trust Incident Reporting Policy.Incident Reporting Policy.

– All incidents occurring during the blood All incidents occurring during the blood transfusion process, regardless of where transfusion process, regardless of where it happens, must be reported to the it happens, must be reported to the blood bank manager.blood bank manager.

BLOOD TRANSFUSION BLOOD TRANSFUSION CAN KILLCAN KILL

SHOT (Serious Hazards of SHOT (Serious Hazards of Transfusion)Transfusion)

A confidential, anonymised, UK A confidential, anonymised, UK wide scheme that aims to wide scheme that aims to collect data on adverse events collect data on adverse events of transfusion of blood and of transfusion of blood and blood productsblood products

SHOTSerious Hazards of Transfusion