Mary Metcalfe & Carmel Parker. Transfusion Practitioners. Ext 8041 bleep 2010 or 8041.

To

gain understanding of best clinical practice involved in Blood/Blood componets therapy. How to safely and appropriately order blood products for transfusion. How to safely set up a transfusion and monitor patients at this point. Management of suspected adverse Transfusion reaction.

Does the patient need blood products. What are the alternative options for treatment. Using the product that will be most effective in providing the desired outcome. Cost. Minimum donor exposure. What is the patients view of treatment.

The London and South East Joint Technical Advisory Groups Transfusion Training Committee

Patient clinical details and presentation. Up to date blood results. Transfusion history and any adverse events. Drug history and dosage. Colleagues, patient, nursing staff, family members are a viable source of information. Transfusion policy and practitioners, lab staff.

EU directive Blood Safety 2002/98/EU. Transposed into law in November 2005. Vein-to-vein traceability. Set standards for collection, processing,distribution,testing and storage of products. Record keeping extended to 30 YEARS.!!

Operational Impact Group

Check the patients details and case note history. Are special requirements needed? E.g. CMV or irradiated. Use the indication codes for RBC & FFP. Is it an appropriate transfusion, what are the alternatives? Is it an EMERGENCY or is it routine.

Aims of the session

Transfusion Reactions/Review & feedback

Station 1.Hospital Blood Bank/products.

Station 3. Blood administration

Station 2. Venous Sampling - risk

NEAR MISS EVENTS 1997/98 - 2003 (n=2427)

8% 10% <1%
Sample errors (1381)

Laboratory component selection handling, storage & issue errors (333) Laboratory sample handling &/or testing errors (279)

11% 57%
Component collection, transportation, ward handling & administration errors (248) Request errors (185)

14%
Miscellaneous errors (1)

Acute blood loss R1 To maintain circulating blood volume and Hb>7g/dl Peri-operative, assuming normovolaemia R2 Hb < 7 g/dl R3 Hb < 9 g/dl in presence of cardiovascular disease or significant risk factors for cardiovascular disease R4 Critical care: Transfuse to maintain Hb > 7 g/dl (>9g/dl if at risk as R3) R5 Post-chemotherapy; there is no evidence base guide to practice usually Hb 8 or 9 g/dl R6 Radiotherapy: transfuse to maintain Hb > 10 g/dl R7 Chronic Anaemia: transfuse to maintain the haemoglobin just above lowest concentration that is not associated with symptoms of anaemia.

 Check the patients case note Transfusion history Special requirements - e.g., irradiated, CMV negative Complete request form or order communications

Information found on the Request Forms

Casenote Surname Forename DOB Ethnic Origin Location Consultant Sex Patient Category NHS Date of Request Entered by Originator Date of Specimen

Service (Type of Request) Blood Group Previous Transfusion

Units (amount) Date Reqd Reaction

Specimen type Vacutainer 7mls pink + 4.5 mls EDTA Antibodies

Specimen taken by Sign and print Name

Requesting Medic Sign and Print name

Copy of this request must be filed in the notes. See Trust Transfusion policy Diagnosis, referral reason, relevant medication

Step 1: Ask the patient to tell you their:

Full Name + Date of Birth

Check this information against the patients ID wristband

Be extra vigilant when checking the identity of the unconscious / compromised patient

Sampling Procedure

Only bleed one patient at a time using Aseptic non touch technique Do NOT use pre-labeled tubes Label the sample tube beside the patient Send the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergency Remember emergency requests must always be phoned through to the Transfusion Laboratory.

Labelling the venous blood sample

Information to include: Full name Date of birth Hospital number Gender Date Signature of person who has taken the sample

At the bedside By the person taking the sample

Positive Patient Identification

Confirm the details with the patient/carer Check the Nameband
Documentation

Do Not Pre-label samples

Recheck the details all correspond

When is the transfusion required? Does the patient have any special requirements? Have they had previous transfusion or reaction, if so when?

Taking the Samples

Quality of the sample Technique Diluted Samples

Positive Patient Identification

I cdnuolt blveiee that I cluod aulaclty uesdnatnrd what I was rdgnieg The phaonmneal pweor of the hmuan mnid

Patient X bled into a pre-labelled sample tube with patient Ys details Patient Y (23 year old) experienced a post-op haemorrhage Patient Y was Group O and received a unit of group A red cells Patient complained of loin pain - transfusion reaction queried but transfusion continued Patient developed renal failure Patient died as a direct result of incompatible transfusion

IV Blood/ Blood Component Chart

Observations must be recorded please ensure all detail are complete on the prescription chart e.g. all patient details.

Each unit must be entered separately on the patients prescription sheet. The entry must specify the type of product any special requirements the rate of transfusion max 4hrs/unit

Blood Transfusion Administration

Found on all Wards/Units & Hospital Intranet

Decision to Transfuse
Communicate with patient

Patient information leaflet

Document in patient notes

Minimum Transfusion Dataset: the following should be documented in the notes

Reason for transfusion Current blood results Component type and amount to be prescribed Anticipated outcome Any reported transfusion adverse events/reactions Review following the transfusion including how much blood has been transfused

There are no special requirements and selection would be dependant on the desired infusion rate

WHY WARM BLOOD ?

PATIENTS UNDERGOING SURGERY WILL ALREADY BE LOSING BODY HEAT DUE TO WOUND OR CAVITY EXPOSURE LARGE VOLUMES OF COLD BLOOD MAY INDUCE HYPOTHERMIA OR CARDIAC ARYTHMIAS

Exchange transfusion

If requested by the laboratory. i.e.. The has cold agglutinins

Never warm blood by any other method

patient

1st checkers
Registered Nurse/ Midwife or Sick Childrens Nurse, Doctor & a qualified Agency Nurse that holds a Trust contract

2nd Checkers
Any of the above & Qualified Theatre Practitioner or qualified agency nurse that does not hold a Trust Contract.

Base line observations Temperature, pulse and blood pressure Further observations (as above) at 15 minutes

A set of observations at the end of transfusion

More frequently if the patient is unwell, unobservable, unconscious or a child.

Ensure the venflon is secure, patent and there are no signs of inflammation Give the patient the call bell Patients should remain in a clinical area for the duration of the Transfusion Review the patients fluid balance and medication.

Pre-administration Procedure
Step 1: Check the blood component has been prescribed Step 2: Undertake baseline observations

Step 3: Undertake visual inspection

LEAKS DISCOLOURATIO N CLUMPING EXPIRY DATE

If there is ANY discrepancy - DO NOT transfuse

Pre-administration checks
Personal checks: - ANTT - wear personal protective equipment Equipment checks: - Personal protective equipment is available and is clean and sterile - A correctly completed prescription chart - Observation chart - Giving set - Disposable bags - Trolley

Step 1: Ask the patient to tell you their:

Full Name + Date of Birth

Check this information against the patients ID wristband

Be extra vigilant when checking the identity of the unconscious / compromised patient

Administration Procedure
Step 2: Check the patients
First name Surname Date of birth Hospital number

on the compatibility/ traceability label against the patients ID wristband

Step 3: Check the compatibility/traceability label with the

blood bag label

Administration Procedure

Any discrepancies DO NOT TRANSFUSE !

Blood Component Bedside Check Procedure

SURNAME FIRST NAME(s) HOSPITAL NUMBER D.O.B.BLOOD GROUP (Patient and Unit)

DONOR NUMBER
EXPIRY DATE Special Requirements

Stop the Transfusion and seek Medical Input and inform the Transfusion Laboratory staff Check the Blood component matches the patient details Replace the unit and giving set with Normal Saline 0.9% Send the discontinued unit with giving set attached back to transfusion capped off at the end with a white venflon cap and any previous transfused bags sealed with the blue plugs all in biohazard bags Documentation (complete the checklist) Complete a Trust Incident form

CATEGORIES OF ADVERSE EVENT REPORTABLE TO SHOT Incorrect blood component transfused (IBCT)
Transfusion transmitted infection (TTI) Immune complications Transfusion-related acute lung injury (TRALI) Acute transfusion reaction (ATR) - <24hrs Febrile transfusion reactions Delayed transfusion reaction (DHTR) - >24hrs Transfusion-associated graft-versus-host-disease (TA-GVHD) Post-transfusion purpura (PTP) Near Miss events

Signs:
Fever (1.5 C rise) Tachycardia Hypotension Haemoglobinaemia Haemoglobinuria Generalised oozing from wounds

Symptoms:
Apprehension Agitation Flushing Pain at cannula site Pain in abdomen, flank Or chest

Delayed Haemolytic Transfusion Reaction

Usually occur in patients who have developed antibodies in the past, from transfusion or pregnancy. These may be undetectable when the patient is tested. However when the patient receives a transfusion this can boost the production of antibodies.

Fever and any other symptoms/signs of haemolysis more than 24 hours after transfusion Unexpected fall in Hb May have postive Direct Antiglobulin test (Coombs test) or positive crossmatch Consider sending samples to the NBS

Non-Haemolytic Febrile (Fever) Transfusion Reaction

Between 1-2% of transfused patients experience some sort of febrile reaction Caused by antibodies in the patients plasma reacting against the leucocytes in the donors blood

Fever or rigor 30 - 60 minutes after the start of the unit +/- rash
TREATMENT:

Stop the transfusion

Give antipyretic e.g. Paracetamol +/- Piriton Continue transfusion if symptomes subside.

Transfusions of blood & blood components are labour intensive & expensive but are frequently life saving events In a few patients, however they can result in potentially fatal complications It is therefore essential that they are only given when the benefits outweigh the risks

The donors blood (the graft) mounts an immune response against the recipient (the Host)
There is no effective treatment and the condition is nearly always fatal

Platelet antibodies from the donor destroy the recipients platelets These lowered platelet levels cause bleeding from micro vessels in to the skin. This manifests as purple areas ( purpura ) seen on the patients skin

Definition Thrombocytopenia within 12 days after transfusion of red cells, associated with the presence in the patient of antibodies directed again the HPA systems. Need to exclude DIC Need to send blood for HPA typing and antibody screen

Viral infections screened for at the time of donation Bacterial infections from contaminated blood components

Each unit of blood contains 250 mg of iron

For patients on long term transfusion therapy this starts to accumulate and become toxic causing damage to the liver heart, pancreas and organs of the endocrine system

Drug therapy is given to excrete this excess

Fluid Overload Caused when too much fluid is transfused or the transfusion is to rapid

Signs & Symptoms include Acute Left ventricular failure,dyspnoea, Hypotension, Tachycardia raised jugular venous pressure

Signs & Symptoms can range from:

Mild and common (estimated risk 1 in100

Urticaria (a raised red itching rash) Treated with an antihisamine with the transfusion being recommenced if the symptoms subside To Rare (estimated risk 1 in 500,000) but very severe and sometimes fatal anaphylaxis manifesting in:- low BP, laboured breathing or oedema, respiratory and cardiac arrest respiratory & cardiac arrest

Caused by antibodies in the donors plasma reacting strongly with the patients leucocytes Signs & Symptoms Transfusion is followed by a rapid onset of breathlessness and non productive cough Chest x ray characteristically shows bilateral pulmonary infiltrates or white out

Acute dyspnoea with hypoxia and bilateral pulmonary infiltrates during or within 6 hours of transfusion Inform transfusion as soon as possible Treat as adult respiratory distress syndrome Need to inform the National Blood Service

What is this? What is wrong with it? What would you do if you saw it?

Can occur during collection, storage & the handling processes

Bacterial Contamination Estimated frequency

per unit

Red Cells Platelets

1/500,000 1/12,000

An Acute medical emergency

Caused by ABO incompatible transfused red cells. Probably due to misidentification of The patient The product or The sample
Seek Haematology Input immediately

Asymptomatic Haemolysis Renal failure DIC Death

Stop the Transfusion and seek Medical Input and inform the Transfusion Laboratory staff Check the Blood component matches the patient details Replace the unit and giving set with Normal Saline 0.9% Send the discontinued unit with giving set attached back to transfusion capped off at the end with a white venflon cap and any previous transfused bags sealed with the blue plugs all in biohazard bags Documentation (complete the checklist)

Complete a Trust Incident form

Transfusions of blood & blood components are labour intensive & expensive but are frequently life saving

In a few patients, however they can result in potentially fatal complications.

It is therefore essential that they are only given when the benefits outweigh the risks