QUICK REFERENCE GUIDE - porthosp.nhs.uk · Web viewThe middle traceability label stating ‘Complete and affix this label to transfusion pathway record’ must be ... hyper/hypotension,

TRANSFUSION POLICY (ADULT)

Version 10

Name of responsible (ratifying) committee Hospital Transfusion Committee

Date ratified 06 July 2018

Document Manager (job title) Transfusion Practitioner

Date issued 02 August 2018

Review date 05 July 2021

Electronic location Clinical Policies

Related Procedural Documents

Patient Identification Policy; Consent to Examination and Treatment Policy; Management of Adverse Events and Near Misses; Management of Serious Incidents Requiring Investigations; Massive Transfusion (Haemorrhage) Guideline; Policy for the Care of Patients Who Wish to Decline Transfusions

Key Words (to aid with searching)Blood; Platelets; Red Cells; Adverse Transfusion Reactions; Administration; Observations; Blood Components; Administration Sets; Plasma; Blood Transfusion; Consent; Blood Warmers; Jehovah’s Witnesses; Religious Beliefs; Training;

Version TrackingVersion Date

RatifiedBrief Summary of Changes Author

10 06/07/2018 ‘Blood’ removed from title; Indication codes updated; Platelets and frozen components now included (adapted from guidelines on pharmacy pages); Consent sticker now mandatory; “Should” changed to “Must” throughout

K Heron / Sue Chambers

9 22/04/2016 Title. Minor adjustments throughout. Indication Codes; Special Requirements; Consent Sticker; Written Instruction and Observation Sheet; Flyer Information; Reaction Flow Chart.

K Heron / Sue Chambers

8 26/10/2012 - J Hickey

Transfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 1 of 37

CONTENTS

QUICK REFERENCE GUIDE..........................................................................................................................3

1. INTRODUCTION......................................................................................................................................5

2. PURPOSE................................................................................................................................................5

3. SCOPE.....................................................................................................................................................5

4. DEFINITIONS...........................................................................................................................................6

5. DUTIES AND RESPONSIBILITIES..........................................................................................................6

6. PROCESS................................................................................................................................................8

7. MANAGEMENT OF ADVERSE TRANSFUSION REACTIONS.............................................................14

8. RAPID INFUSIONS AND BLOOD WARMERS......................................................................................16

9. STORAGE..............................................................................................................................................16

10. USE OF PLATELETS.........................................................................................................................16

11. USE OF FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATE...........................................19

12. TRAINING REQUIREMENTS.............................................................................................................20

13. REFERENCES AND ASSOCIATED DOCUMENTATION..................................................................20

14. EQUALITY IMPACT STATEMENT.....................................................................................................21

15. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS...............................................22

APPENDIX 1: Indication Codes for Transfusion............................................................................................23

APPENDIX 2: Blood Transfusion, Size Matters!............................................................................................26

APPENDIX 3: Consent for Transfusion.........................................................................................................28

APPENDIX 4: Written Instruction...................................................................................................................29

APPENDIX 5: Blood Component Specific Requirements..............................................................................31

APPENDIX 6: Emergency Blood Issue..........................................................................................................33

APPENDIX 7: Acute Transfusion Reactions (ATR).......................................................................................34

APPENDIX 8: Common Complications Associated with Transfusion of a Blood Component.......................35

APPENDIX 9: Modified WHO Bleeding Score...............................................................................................37

EQUALITY IMPACT SCREENING TOOL.....................................................................................................38


QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Obtaining consent for all transfusions is a Department of Health requirement and is the responsibility of the Clinician or Non-Medical Authoriser making the decision to transfuse. Do not forget the rights of the competent patient to refuse a transfusion or request an alternative treatment, if available. Transfusion Patient Information Leaflets are available and must be offered

2. Transfusion written instruction (prescription) must include four patient specific identifiers: surname, first name, date of birth and NHS number. If patient has no NHS number write on request form “NHS number not available” and use Casenote/Hospital/PAS number. For “unknown” patients (primarily ED) use ED number, unknown and gender. Type of blood component, specific requirements (e.g. CMV negative, irradiated etc.), quantity to be given, duration and rate of infusion, name and signature of Clinician or Non-Medical Authoriser

3. Only suitably trained registered practitioners can request blood and blood components. Request forms must contain the four markers of patient identification (PID) as above, together with the reason for transfusion (Indication Code, appendix i, page 24), date and time required, name and signature of requesting Clinician or Non-Medical Authoriser, and the location

4. Only suitably trained staff may take samples for group and screen and cross-matching. The sample must be taken into an EDTA (pink top) tube. These must be correctly labelled by hand, beside the patient, from the PID band (inpatients), with the four points of ID and they must be dated, timed and signed. All samples must be labelled by the staff member who took the sample

5. When a cross-match is requested and the patient does not have a historical group recorded on the Apex (LIMS) computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the group has been verified. Whilst there is no time specification between the two samples, they MUST NOT be taken at the same time. Ideally taken by a different practitioner and must be sent with a separate request form

6. A consent sticker (appendix iii, page 29) must be used to document, that the process of gaining informed consent has taken place

7. All staff collecting blood and blood components must have initial training then annual revalidation. All staff are responsible for ensuring their training needs have been met.

8. Before collecting the blood or blood component, ensure the patient is ready to receive the transfusion and has the correct PID band in situ.

9. When collecting blood or blood components, staff must check the four specific points of PID (as above) they have brought with them against the component label before scanning it out of the issue fridge or signing for it from within the Transfusion Laboratory (any discrepancies must be reported to a member of the Transfusion Laboratory staff immediately)

10. Blood and blood components must be commenced, or returned to the Transfusion Laboratory within 30 minutes from collection

11. Before administration the specific four points of PID (as above) must be checked against the component label and the PID band at the side of the patient. Do not connect any components unless you have checked all the details are correct yourself (any discrepancies DO NOT GO AHEAD, report to Transfusion Laboratory staff immediately)


12. Transfusions must be given in clinical areas, where frequent visual and verbal contact with the patient may be maintained

13. As a minimum per unit, the conscious patients’ temperature, pulse, respiratory rate (TPR), blood pressure (BP) and oxygen saturations (O2 Sats) must be checked before the start of the transfusion, 15 minutes following the start of the transfusion and again at the end of the unit. The unconscious patient requires, as a minimum per unit, TPR, BP and O2 Sats before the unit is started, every 15 minutes for the first hour and hourly thereafter

14. Blood and blood component labels must be fully completed. As indicated, one must be returned to the Transfusion Laboratory and one fixed to the patients’ transfusion written instruction/notes

15. Patients must be encouraged to inform a member of staff if at any time during the transfusion they feel unwell (day case patient information leaflets to be given on discharge, available to order from Medical Illustration ref: 14/5879)

16. A giving set used for a blood transfusion must NOT be subsequently used for administering fluids or different blood components

17. Accurate documentation of the transfusion must be maintained

18. Any suspected adverse reaction(s) or events should be communicated to the Transfusion Laboratory staff and/or to the Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE) and a Datix report completed

19. Blood and blood components must NOT be stored in a ward domestic or drug fridge UNDER ANY CIRCUMSTANCE

20. Routine transfusions may be administered overnight, providing the environment is conducive to safe practice enabling close visual monitoring of and verbal communication with the patient and all observations to be carried out and recorded as per this policy. However, if the transfusion could safely wait until the day time then this would be preferable. TRANSFUSIONS MUST TAKE PLACE OVERNIGHT IF THE PATIENT IS BLEEDING OR SYMPTOMATIC

Use of Platelets, page: 19 Use of FFP and Cryoprecipitate, page: 21


1. INTRODUCTION

Appropriate transfusion is an essential support to many medical treatments and can be lifesaving. There are many risks to the patient, including acute haemolytic reactions and transfusion transmitted infections. Incidents affecting the safety of transfusion are highlighted through the Serious Hazards of Transfusion (SHOT) haemovigilance scheme. This scheme has shown that avoidable, serious hazards of transfusion continue to occur in Trusts throughout the UK, the most frequent factor being human error. Out of 3091 total reported incidents, 87% were caused by human error (often multiple errors). There has been little progress in the last decade (Annual SHOT Report 2016, July 2017).

Stringent procedures must be followed to ensure that the correct blood/blood component is always given and that any adverse reactions are dealt with promptly and efficiently.

Procedures for requesting, writing up and the administration of blood and blood components, as well as the management of any complications support this clinical policy on transfusion. Procedures for the documentation of transfusions in nursing, medical and laboratory records are also provided, including the procedure for the reporting of any adverse reactions or events occurring in relation to transfusions.

This clinical policy has been revised to clarify terminology, incorporating core standards in transfusion practice in adult patients.

Neonatal Intensive Care patients are one of the most transfused groups and because of their potential normal life expectancy they are more susceptible to the long-term effects of transfusion. Particular care and attention must be given to neonates and children to minimise blood component use. See local departmental PHT policy for neonatal and paediatric practice. This policy reflects the Blood Safety and Quality Regulations (BSQR) 2005, current NICE guidelines and BSH recommendations.

2. PURPOSE

The purpose of this policy is to:

Provide a clear framework and guidance for safe transfusion practice, throughout Portsmouth Hospitals NHS Trust (the Trust)

Ensure a consistent approach to the requesting, writing up, handling and administration of blood and blood components throughout the Trust

Ensure that all members of staff involved at any stage of the process of transfusing blood and blood components are aware of their role and the legal aspects of this practice

3. SCOPE

This policy applies to all staff involved in the requesting, sampling, prescribing, storing, collecting, transporting and administering of human blood and blood components, including those who work in Primary Care Trusts supplied with blood/blood components from the Trust Transfusion Laboratory.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on going patient and staff safety’


4. DEFINITIONS

Transfusion: blood or any of its components used to correct or treat a clinical abnormality

Blood component: red cells, platelet concentrate, fresh frozen plasma (FFP), OctaplasLG®, and cryoprecipitate

Blood Product: any drug which is manufactured using human blood components

Patient Blood Management (PBM): a standard of care that focuses on measures to reduce or avoid the need for transfusion if possible. If a transfusion is needed, the aim is to ensure that the patients are only given what they really need and that the transfusion is given safely

Cold chain: the legal requirements to monitor transport and storage conditions of blood components, from donor to recipient

Maximum Surgical Blood Ordering Schedule (MSBOS): the Trust’s agreed maximum number of cross-matched units or group and screen testing requirements for surgical procedures

Medicines and Healthcare Products Regulatory Agency (MHRA): An executive agency which aims to enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safe

Serious Adverse Blood Reactions and Events (SABRE): the MHRA reporting scheme to which serious adverse reactions and events related to blood components / products are reported

Serious Hazards of Transfusion (SHOT): the United Kingdom’s independent, professionally-led haemovigilance scheme, responsible for recording and monitoring all blood component adverse events and reactions

Serious Incidents Requiring Investigation (SIRI): Trust system for investigating Amber or Red incidents and events

5. DUTIES AND RESPONSIBILITIES

(A)The Hospital Transfusion Committee (HTC)

The HTC includes members of the Hospital Transfusion Team and representatives from all clinical areas where blood and blood components are administered.

Responsible for:

Overseeing all aspects of transfusion practice Promoting good transfusion practice based on national guidelines through the provision of a

robust framework to communicate information and advice Arranging for audits of blood and blood component usage to be carried out, in line with local

and national requirements and receiving and reviewing the reports of those audits Making recommendations to address any issues highlighted by the reports and monitoring

the implementation of the actions Receiving quarterly reports from the Hospital Transfusion Team regarding the trends and

themes from adverse incidents, including any variance from this policy and for recommending any actions to address the variance

Reviewing all SHOT submissions and ensure the root causes are identified and all necessary action taken to prevent a recurrence

Monitoring the implementation of actions arising from the investigation of SIRI Receiving the results of all audits associated with the transfusion process and developing

any required action plans to address the identified issues Transfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 6 of 37

Undertaking regular review of this policy and recommending any changes as highlighted by audits or adverse incidents

Ensuring any risks associated with the transfusion process are assessed and escalated to the Trust Risk Register

Acting as a forum to discuss advancements in transfusion practice, including PBM and reviewing and amending practices and policies in the light of those advancements

Providing, through the Chair, an annual report on all aspects of transfusion practice, to the Governance and Quality Committee

(B)Hospital Transfusion Team (HTT)

The HTT includes the Clinical Lead for Transfusion, Transfusion Laboratory Manager (TLM), Transfusion Laboratory Seniors, Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE).

Responsible for:

Meeting at least once a month to discuss current issues and incidents Addressing and monitoring any outstanding corrective and preventative actions Informing the decision-making process for new initiatives Ensuring the HTC is informed of any required audits Reporting quarterly to the HTC The review and development of policies and guidelines

(C) Clinical Lead for Transfusion

Responsible for:

Acting as the main point of contact for medical staff, including GP’s, requiring information, advice and guidance on transfusion issues

Submission of clinical information to NHSBT to aid investigation of serious adverse transfusion reactions, in conjunction with TP and TPE

(D) TLM

Responsible for:

Ensuring the Transfusion Laboratory complies with the legislation as set down in the Blood and Safety Quality Regulations (BSQR 2005) and the statutory requirements of the Department of Health to ensure patient and staff safety

Submission of reports to SABRE and/or SHOT, in conjunction with the TP and TPE The investigation of all adverse incidents and near misses associated with any aspect of

transfusion, in conjunction with the TP, TPE and Laboratory Seniors

(E) TP and TPE

Responsible for:

Submission of reports to SHOT and/or SABRE, in conjunction with the TLM and Laboratory Seniors

The investigation of all adverse clinical incidents and near misses associated with any aspect of transfusion

Provide the HTC with quarterly reports on all aspects of transfusion practice, including adverse events

Facilitate education and training for all relevant clinical staff groups Participate in local and national audits and feedback results to HTT and HTC Maintain and update relevant clinical policies


Provide advice and support on transfusion matters to clinical staff

(F) Clinicians Including Non-Medical Authorisers

Responsible for:

The decision to transfuse in conjunction with NHSBT indication codes (appendix i, page 24) For stable, non bleeding patients consideration must be made that each unit is a separate

clinical decision in conjunction with the potential risk of Transfusion Associated Circulatory Overload (TACO), see appendix ii, page 27

The consent process, sticker (appendix iii, page 29) must be fully completed and placed into the patients’ notes. Patient written information leaflets must be offered, these are available from TP and TPE

Where practical, informing patients of alternatives to transfusion Full completion of Transfusion Written Instruction (appendix iv, page 30) Ensure any specific requirements are met (appendix v, page 32)

(G)All Ward and Line Managers

Responsible for:

Being aware of this policy and associated policies and guidelines Releasing staff for training Integrating compliance into the Knowledge and Skills Framework (KSF) and Annual

Performance and Development Appraisals (APDR) for all their staff Ensuring appropriate evidence of compliance is gained during the APDR process Ensuring their staff are aware of and understand this policy and comply with its content Communicating any concerns regarding staff compliance with this policy to the TP/TPE

(H)All Staff Involved in the Processes Associated with Transfusion

Responsible for:

Being aware of this policy and associated policies and guidelines Comply with this policy at a level commensurate with their involvement Attending training relevant to their role in the process Report all adverse events and near misses on Datix to enable investigation/monitoring by

TP/TPE

6. PROCESS

Note: whilst the same principles apply to all patients regardless of age, there are some very specific issues which relate to neonates and paediatrics, see local PHT departmental guidelines. For renal patients see speciality guidelines and policies, WRTS Blood Administration: Adults on Haemodialysis/Haemofiltration.

(A)Consent

Obtaining consent for a transfusion is a Department of Health requirement and it is the responsibility of the prescribing Clinician or Non-Medical Authoriser to obtain and document that consent in accordance with Trust Policy and provide written information (leaflets available from TP and TPE). If the patient is unable to provide consent, this must also be documented in the notes. Refer to the Trust ‘Consent to Examination and Treatment Policy’. In order to facilitate the documentation of consent, stickers must be used, these are available from Medical Illustration and must be completed and placed in the patients’ notes (appendix iii, page 29)


Where practical, patients must be informed of the reason for the transfusion, the potential risks and benefits involved. They should also be informed of their right to refuse the transfusion but must then be advised of the risks of doing so

All staff, but particularly those taking consent must be aware:

o Of the beliefs of the Jehovah’s Witness in relation to receiving any blood component and medical alternatives, which may be applicable

o That an individual patient may accept different treatments such as dialysis, cardiopulmonary bypass, organ transplants, and non-blood replacement fluids of plasma derivatives, iron therapy and cell salvage

o That any patient may have valid personal reasons or beliefs for not wishing to have a transfusion

o That each patient has the right to be treated with respect and staff must be sensitive to their individual needs, acknowledging their values, beliefs and cultural background

o The patient must be provided with information about alternatives to transfusion, where appropriate, including autologous transfusion

o In circumstances where a patient lacks the capacity to consent and it is an emergency or urgent situation, treatment can be provided on the basis of ‘best interests’. There is a tick box to indicate this on the consent sticker and also a patient information leaflet available for patients who have received an unexpected blood transfusion (obtain from TP and TPE)

o In elective situations the healthcare professional seeking consent must consider whether the patient has put in place a valid and applicable Advanced Decision, which covers the refusal of a transfusion

For guidance regarding religious or personal beliefs refer to the Trust’s Policy on the Care of Patients Who Wish to Decline Transfusions

o Further guidance can be obtained from the Trust’s Legal Services Manager

(B)Blood Sampling

Only suitably trained and competent staff may perform phlebotomy for group and antibody screen and cross-matching

All blood samples must be taken in accordance with Trust Policy (refer to Blood Sampling Policy (Adults)

The sample must be taken into an EDTA (pink top) tube and immediately labelled at the side of the patient by the staff member who took the sample. The sample must be labelled appropriately, with the specific four points of PID – Surname, First name, DOB, NHS number and be dated, timed and signed. No amendments accepted

Pre labelled tubes and addressograph labels MUST NOT be used When a cross-match is requested and the patient does not have a historical group recorded

on the Apex computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the second sample has been verified. Whilst there is no time specification between the two samples, they MUST NOT be taken at the same time. Ideally taken by a different practitioner and must be sent sent with a separate request form

Samples are valid for 7 days UNLESSo The patient has been transfused or pregnant in the previous 3 monthso THEN the sample is only valid for 72 hourso For planned C-section valid for 96 hourso These timings include any transfusion time

All transfusion samples must be labelled by handTransfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 9 of 37

(C)Requesting Blood and Blood Components

For Emergency Issue of Blood or activation of the Massive Transfusion (Haemorrhage) Guideline

Call ext: 4444 Only suitably trained registered Clinicians and Non-Medical Authorisers can request blood and

blood components Request forms must contain the four specific PID identifiers (Forename, Surname, DOB and

NHS Number) and include the date and time blood and blood components are required, contact number, clinical details, name and signature. The request may be refused if the form is not completed appropriately

The request form must clearly state any specific requirements e.g. CMV negative/ irradiated (appendix v, page 32)

For patients who cannot supply the relevant information, the name and date of birth can be verified by the patients’ family, carer, guardian or other representative

Requests for blood and blood components will not be processed if the sample is inadequately labelled as previously stated (i.e. must have the four points of PID, be dated, timed and signed, with no amendments and be legible)

Unidentified patients are usually admitted via the ED department. In these circumstances the request form and the sample must be labelled with the identity status of ‘unknown ‘male’ or ‘unknown female’ and ED number

If the unidentified patient is a young person who may have been born after 1st January 1996, this must be made known to the Transfusion Laboratory so appropriate components can be issued, until the actual date of birth is confirmed

For non urgent requests the Transfusion Laboratory usually require 48 hours notice to prepare blood and blood components. If required earlier than 48 hours, call the Transfusion Laboratory on ext. 6539 to discuss the request

Indication codes (appendix i, page 24) are a mandatory field when requesting a cross match on ICE and must also be specified where indicated on the hand written request forms

Where antibodies are identified, selection of blood may take longer as complex cross-matches may require referral to NHSBT in Bristol for testing and/or the sourcing of antigen negative blood from NHSBT

Requests for platelet issue must be made by calling the Transfusion Laboratory, ext. 6539, see table below. Ensure any specific requirements are communicated. All verbal requests must be followed up with an ICE request form printed directly to the transfusion laboratory printer, P062747. Alternatively a hand written form can be sent in the POD system

Also Refer to: Use of Platelets, page 19 Use of FFP and Cryoprecipitate, page 21 Use of OctaplasLG® Guideline within Pharmacy Intranet page. Drug Therapy Guideline

No 161.00 Issued: 25.01.13

(D)Requests for Elective Surgery

Patients who are scheduled for elective surgery must have a group and antibody screen performed at least 48 hours prior to enable any detected antibodies to be fully identified and blood transferred to site

Elective surgery must not be cancelled because of non availability of a group and antibody screen. Suitable units will be made available in the event of an emergency

(E) Written Instruction and Observation Sheet (prescription) (appendix iv, page 30)


Must be completed with the following…..o Patient identifiers (addressograph label)o Patients body weight, think TACO (appendix ii, page 27)o Recent FBC results (inpatients within 24hrs, outpatients within 72hrs)o Date to be transfusedo Blood (written as ‘packed red cells’) or blood component to be transfused, plus any

specific requirements (e.g. CMV negative, irradiated etc.)o Each unit must be written individually. Consider single unit (appendix ii, page 28)o The duration or rate of transfusion (packed red cells 2 or 3 hrs, platelets,

FFP/OctaplasLG® Cryoprecipitate a maximum of 30 minutes)o Name and signature of Clinician or Non-medical Authorisero A new sheet must be used per episode of transfusion (an episode is within a 24 hour

period)

(F) Collection from the Blood Issue Fridge and the Transfusion Laboratory

Before the collection of blood from the issue fridge in Pathology reception, or blood and blood components from the Transfusion Laboratory, staff must check that a written instruction has been correctly and fully completed as above

It is a statutory requirement that all staff collecting blood and blood components have initial training and maintain their access by annual revalidation when asked to do so

Only suitably trained, competent and validated staff may collect blood and blood components

The member of staff must:

Check the patient details on their identity band, notes and written instruction are correct

Remember: No Identity Band, No Transfusion

Ensure there is a suitable, patent cannula for the transfusion (or central line) – ensuring it has been flushed prior to collecting the unit

Ensure your patient is ready and has consented to having the transfusion. Allow time to discuss and alleviate any anxieties

Ensure administration equipment is available (pump, drip stand and appropriate giving set) Take official printed confirmation of the patients’ identity to the issue fridge or Transfusion

Laboratory (written instruction or addressograph label). This must contain the four points of PID, this must match the patients’ identity band

For the issue fridge, swipe their validated ID card to gain access Note: it is a disciplinary offence to use someone else’s card

Select the unit required Confirm the details on the blood compatibility label with the printed confirmation of the

patients’ identity (this must also take place if collecting from within the Transfusion Laboratory. For blood components, all these details must also match the paper printout)

Scan the unit as demonstrated during training, ensuring the unit number appears on the screen

Only one unit per patient must be removed at a time Take the unit directly to the clinical area in which it is required, in the red bag provided, make

no diversions Start the transfusion immediately on return to the clinical area, do not leave to ‘warm up’ Blood and blood components must be either started on the patient or returned to the

Transfusion Laboratory within 30 minutes of removal from cold storage In an emergency or massive haemorrhage situation, (call 4444) a cold box will be issued by

the Transfusion Laboratory staff, see ‘Massive Transfusion (Haemorrhage) Guideline’. Two units will be issued in a red bag, to be started on the patient or returned to the Transfusion Laboratory within 30 minutes. Two units will also be issued in a cold box sealed with a cable


tie. This will keep the blood safe for up to four hours if the cable tie remains intact, see flow chart appendix vi, page 34.

Blood and blood components must NEVER be stored in a ward fridge (domestic or drug)

(G)Administration of Blood and Blood Components

To administer and/or check blood and blood components the staff member must be a Registered Practitioner and suitably trained (firstly completed their IV competency) and have a blood administration competency signed to a minimum of level two

Must be in date on ESR with their ‘Blood Awareness Update’ Transfusions must be administered in the clinical area, where frequent visual and verbal

contact can be maintained Blood and blood components can be administered peripherally or centrally, a Y connector

must NOT be used. No other fluids must be administered at the same time into the same peripheral cannula. However, if a patient has a double lumen central/PICC line with distal and proximal ports, different fluids can be administered at the same time

No other drugs or fluid must be mixed with blood and blood components under any circumstances

The correct giving set must be used for the appropriate blood component and its availability must be confirmed prior to collecting the component. This will prevent any unnecessary delay in starting the transfusion

*Fresh giving sets must be used with a different component. Do not use the same set for different components as clotting may occur

Be pragmatic during an emergency / massive haemorrhage situation

Red Cells: must be administered within a maximum of four hours from leaving cold storage. Slower infusion promotes bacterial growth in the unit. Two hours is suitable for most patients however, those patients with underlying cardiac or respiratory conditions may require the transfusion to be given over three hours

Be aware of the volume being infused – remember the risk of TACO (Information Flyer Appendix 2)

Platelets: Start immediately once received into the clinical area and administer over 30 minutes

FFP/Cryoprecipitate: Start immediately once received into the clinical area and administer ‘stat’, maximum 30 minutes

OctaplasLG®: As for FFP/Cryoprecipitate Volumetric pumps must be used with the appropriate administration set To reduce the risk of transfusion errors, units must be checked at the patients’ bedside.

Remote checking of the unit away from the patient is unacceptable and unsafe. Positive identification of the patient at the bedside is essential and mandatory


Type of Component Type of set Change Set afterRed Cells* Blood giving set with integral

170-200 micron filter12 hours or 4 units of blood (whichever comes first)

Platelets* Blood giving set with integral170-200 micron filter

After each unit

Fresh Frozen Plasma* (FFP)

Blood giving set with integral170-200 micron filter

At the end of the administration

Cryoprecipitate* Blood giving set with integral170-200 micron filter

At the end of the administration

Ensure that all PID markers correspond (blood or blood component label, PID band and all other paperwork and documentation) any discrepancies: DO NOT TRANSFUSE and inform the transfusion laboratory immediately: Extension 6359

Check unit type matches written instruction If a patient is conscious, able to communicate and able to actively take part in the checking

process, it is recommended that a single Registered Practitioner should check the unit with patient at the bedside. The Registered Practitioner must ask the patient to state their surname, first name, date of birth and confirm spelling

All other scenarios, it is required that two registered practitioners check the unit, independently, at the bedside. If required another member of staff or relative/carer can confirm the patient’s identity

In the event of an “unknown” patient, the PID band, which will include the ED number, unknown male/female should be used for checking purposes

Refer to Patient Identification Policy

Remember: No Identity Band – No Transfusion

Any discrepancies – DO NOT transfuse, contact the Transfusion Laboratory and return the unit immediately

The Registered Practitioner(s) must also check the expiry date of the blood or blood component and ensure the donation number e.g. G…………… number and the blood group on the bag corresponds to the attached printed label. Handwritten amendments to PID are NOT permitted

Blood or blood components must never be left unattended or stored in the clinical area under any circumstances

(H)Observations Required for Transfusion (MUST be performed in addition to frequency indicated by VitalPac)

Conscious Patients

Record the patient’s temperature, pulse, respirations (TPR), blood pressure (BP) and oxygen saturations (O² Sats) prior to (collection) starting the transfusion

Ask the patient to report if they are feeling unwell in any way during the transfusion Repeat and record the patients TPR, BP and O² Sats at 15 minutes. This is the crucial time,

as severe reactions frequently occur during this time The recording of further observations and the regularity of those is dependent on the

patients’ underlying condition or if the patient becomes unwell, or shows signs and symptoms of a reaction

Repeat and record the patients TPR, BP and O² Sats at the end of the unit Regular visual observations of skin colour and cannula site must be undertaken Regular verbal communication throughout the transfusion must take place Fluid balance should be recorded on the ‘fluid balance’ chart

Unconscious Patients

In addition to the observations for a conscious patient:

Repeat the TPR, BP and O² Sats every 15 minutes for the first hour and hourly thereafter if patient stable

(I) Transfusing at NightTransfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 13 of 37

If the patient is bleeding and/or unstable, transfusions MUST always take place overnight

Routine transfusions may be administered overnight, providing the environment is conducive to safe practice. Patient safety is paramount. Ensure close visual and verbal monitoring of the patient throughout the entire transfusion episode and all observations must be carried out and recorded as per this policy. However, if the transfusion could safely wait until the following morning, then this would be preferable

(J) Documentation

It must be documented in the patients’ medical notes the reason for the transfusion and where the patient is able, that a conversation has taken place between the prescribing Clinician or Non-medical Authoriser and the patient about the risks and benefits associated with transfusion

Consent sticker (appendix iii, page 29) must be used to document informed consent has taken place

The component type, amount administered and any adverse effects The middle traceability label stating ‘Complete and affix this label to transfusion pathway

record’ must be filled in appropriately and placed on side two of the written instruction (appendix iv, page 30)

Detach the ‘Return to transfusion’ traceability label which must be filled in appropriately with date, time, name and signature of administrator and returned to the Transfusion Laboratory in the envelope provided once the unit is connected to the patient. This is a legal requirement, therefore a Datix report will be entered for all non returned labels or if they are returned but without date and time of transfusion and signature

In an emergency where administration of ‘emergency group O’ units has taken place, the labels MUST be completed with the details of the patient who received the unit, in addition to the information stated above

Once the transfusion episode is completed, the written instruction must be filed in the patients’ medical notes in the appropriate date area of the history sheets

7. MANAGEMENT OF ADVERSE TRANSFUSION REACTIONS (Flow chart, Appendix 7; Table of common complications associated with transfusion of a

blood component, Appendix 8)

Patients with severe reactions can deteriorate very quickly with hypotension, respiratory distress, collapse and possible death

Remember single unit transfusions reduce the risk of an adverse reaction

(A)Acute Transfusion Reactions (ATRs)

Present within 24 hours of transfusion and vary in severity from mild febrile to allergic reactions to life threatening events. They include:

o Febrile non-haemolytic transfusion reactions – usually clinically mildo Allergic transfusion reactions – ranging from mild urticarial to life-threatening angio-

oedema or anaphylaxiso Acute haemolytic transfusion reactions – e.g. ABO incompatibility o Bacterial contamination of blood unit – range from mild pyrexial reactions to rapidly

lethal septic shock depending on specieso Transfusion-associated circulatory overload (TACO)o Transfusion-associated acute lung injury (TRALI)


Possible features of an acute transfusion reaction, which may include, but are not limited to:o Patient in distresso Restlessness/ behavioural changeso Pyrexiao Chillso Rigorso Tachycardiao Hyper/hypotensiono Flushing/palloro Headache o Pain at or near transfusion cannula siteo Urticariao Anaphylaxiso Pain (bone, muscle, chest, abdominal, loin, back)o Dyspnoeao Respiratory distresso Nausea/vomitingo General malaiseo Haemoglobinuria/haematuriao Collapse

(B)Suspected Minor Reaction

Pyrexia of < 2º C from baseline and/or pruritus or rash WITHOUT other features: The transfusion can be slowed down and continued with direct observation and possible

treatment with oral paracetamol (adult dose 500-1000mg) and/or antihistamine (adult dose of chlorphenamine 10mg IV). If hydrocortisone is required the standard dose for an adult is 100mg by slow IV injection

If transfusion is discontinued follow suspected transfusion reaction process as below

(C)Suspected Moderate/Severe Reaction

Pyrexia of ≥ 2º C from baseline and/or chills, rigors, tachycardia, hyper/hypotension, urticaria, anaphylaxis, chest/back/abdominal/bone pain, dyspnoea, respiratory distress, nausea/vomiting, haemoglobinuria/haematuria, collapse

Stop the transfusion, call for medical assistance, check PID and unit compatibility label, maintain venous access, resuscitate and treat symptoms

Return implicated unit bag, with giving set, and any previous transfusion unit bags that have been used in this episode to the Transfusion Laboratory

Fully complete the ‘Investigation of Suspected Transfusion Reaction’ form (available only from the Transfusion Laboratory) and return promptly to the Transfusion Laboratory

Follow documentation as below

(D)Documentation of ATRs/Incidents

All transfusion (including ‘near miss’) incidents and suspected ATRs must be reported on the Trust’s ‘Safety Learning Event’ DATIX system (accessible from desktop icon)

TP/TPE will be alerted to transfusion related incidents entered onto DATIX. They will ensure correct process has been followed

Document clearly and concisely in patient’s notes Any ‘wrong blood component in patient’ or other major incident must be recorded as a SIRI

and fully investigated in accordance with Trust Policy. Inform TP/TPE ASAP All ATR’s and any other adverse incidents will be discussed by the HTT and reported

quarterly to the HTC Transfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 15 of 37

(E) SHOT/ SABRE Reporting

Various incidents including moderate/severe ATRs will be reported to SHOT/SABRE as required to by the TP/TPE

SHOT suggest that TACO and TRALI are under reported. Therefore any suspicion of these, contact the TP (Monday – Friday 0800-1600) and the on-call Haematologist via the Trust switchboard

8. RAPID INFUSIONS AND BLOOD WARMERS

The routine warming of blood is not necessary Warming the blood increases the risk of bacterial growth, so should not be used except in the

following circumstances:o Massive haemorrhage where level one infusers are usedo Neonates/Infants requiring exchange transfusiono Patients who have clinically significant cold agglutinin antibodieso Patients who are hypothermic or at risk of becoming hypothermic due to complicated

or prolonged surgery

If blood is required to be warmed, this must only be completed using a specifically designed commercial device, with a visible thermometer and audible alarm which ensures the blood is not warmed over 410C

The device must be monitored and validated every twelve months. Blood warmers are extremely dangerous if they malfunction

9. STORAGE

Blood is only to be stored in a purpose built, fully validated and alarmed fridge at between 2 and 60C, in accordance with BSQR (2005). This prevents the risk of bacterial growth. Note: The alarm is connected to the Hospital switchboard to alert of any malfunction

Blood must NEVER be stored in a ward/departmental drug or food fridge Red cells must be either started on the patient or returned to the issue fridge/Transfusion

Laboratory within 30 minutes of removal from cold storage Blood components must be transfused as soon as possible following removal from the

Transfusion Laboratory to ensure they are at optimum quality. All unused units must be returned to the Transfusion Laboratory. These components must never be stored at ward/departmental level

10. USE OF PLATELETS

Platelet transfusions are an essential component in the management of selected patients with thrombocytopenia. However they need to be used judiciously as they are a limited resource and are not risk-free.

Background

Platelet transfusion fall into two broad categories, either ‘therapeutic’, to treat bleeding, or ‘prophylactic’, to prevent bleeding. This is based on the modified World Health Organization (WHO) bleeding score (appendix ix, page 38). Recommendations for prophylactic transfusion relate to patients with bleeding score of 0 or 1 and therapeutic transfusion to patients with bleeding score of 2 or higher.

This can be divided into 3 distinct situations.Transfusion PolicyVersion: 10Date of Issue: Review Date: 05 July 2021 (unless requirements change) Page 16 of 37

Prophylactic (WHO bleeding score 0 or 1) to prevent bleeding o Routine use in non-bleeding patientso In the presence of additional risk factors for bleeding e.g. sepsis or abnormalities of

haemostasis Pre-procedure to prevent bleeding expected to occur during surgery/invasive procedure Therapeutic (WHO bleeding score ≥2) to treat active bleeding

Indications for the use of Platelet transfusion appendix i, page 25.

Standard available platelets can be apheresis (single donor) or pooled (multi donor). This does not affect their usage or efficacy.

Certain specialised products are available after discussion with a Haematologist. These include HLA matched platelets, Irradiated platelets (appendix v, page 32), neonatal or intrauterine components.

Platelets are kept at room temperature and therefore have a short shelf life - currently 5 days although recently some units are given a 7 day shelf life. A single unit is usually adequate for prophylaxis. One adult therapeutic dose (ATD) should give a rise in platelet count of 20 – 40 x 109/L.

Infection is a major risk in transfusing platelets. Much of this risk is because they are kept at room temperature.

Requirements for issuing Platelets Known Blood group recorded on Laboratory Computer. Thrombocytopenia with no contraindication for use of platelets Issue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automatic

Contraindication to Transfusion of Platelets. Thrombotic Thrombocytopenic Purpura (TTP)

– Can make TTP worse so are contraindicated unless haemorrhage is life threatening. BSH guidelines on TTP should be consulted for these rare patients

Heparin Induced Thrombocytopenia (HIT)– This thrombocytopenia is associated with severe thrombosis. Heparin should be

withdrawn, including IV flushes and low molecular weight heparin. Platelet transfusion is contraindicated. Platelets aggregate with heparin – giving platelets can drive this aggregation and can cause arterial thrombosis

Ordering platelets from the Transfusion Laboratory

The Transfusion Laboratory hold a limited supply for emergency use only. The short shelf life means they are only supplied at the time they are required. The laboratory has a stock rotation policy to reduce wastage

Full patient identifiers and known blood group are required. If no blood group is known, and is not recorded on the laboratory computer, a group & screen sample must be sent with the order

The approval of a haematologist is required to ensure appropriate usage, with the exception of DCCQ and NICU

Requests for platelets must be made by calling the Transfusion Laboratory, ext. 6539, see table below. Ensure any specific requirements are communicated. All verbal requests must be followed up with an ICE request form printed directly to the transfusion laboratory printer, P062747; or a hand written form can be sent in the POD system

Do not over order, see table below

TYPE ORDER TIME TIME DELIVEREDUP TO 16:15 19:00


STANDARD PLTS

Mon-Fri16:16 – 07:00Mon-Thurs

11:00

16:16 Friday - 07:00 Mon(weekend)

11:00 Monday

HLA PLTS24 hours

notice minimum

UP TO 11:00Mon – Thurs

11:00 The following day

11:01 Thurs- 16:30 Thurs 19:00 Friday

16:31Thurs- 11:00 Sun 11:00 Monday

WASHED PLTS

48 hours notice

48 hours notice On the first Routine delivery after 48 hours 11:00 or 19:00

If required urgently, random platelets may be issued on the advice of a Haematologist (Laboratory staff will advise accordingly)

If platelets are required outside these times CONSULTANT approval is required. This will only be for instances of Emergency where random stock platelets are not available

Following prophylactic platelet transfusions, always review the patients’ response to each bag before ordering more.

Which ABO group will be supplied?

Usually the same as the patients’ ABO group but you may be supplied with another group that will be compatible. This will depend upon platelet stock availability, especially if patient has specific requirements e.g. HLA, irradiated. NB. Compatibility of ABO groups differ in platelet and plasma components from red cells

Rh D group:

Rh D negative components will be given, when possible, and particularly to females who are Rh D negative or unknown and <55 years old

If Rh D positive platelets are given to RhD negative women who are <55 years old then prophylactic Anti D should be administered – 250 units for every 5 adult doses of platelets in a 6 week period.

Anti D is not required for Rh D negative/unknown males, or women ≥ 55 years

Response to platelet transfusion

A repeat FBC must be taken after platelet transfusion in bleeding patients or before critical procedures to ensure there has been an increment.

For prophylactic indications for platelets – you can use the next morning’s FBC if an inpatient.The 10 minute or 1-hour post platelet transfusion FBC can be used for day cases.


11. USE OF FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATE

Please note patients born after 1st January 1996 or unknown, and/or plasma exchange will be issued OctaplasLG® in place of FFP and Methylene Blue Cryoprecipitate as per national guidance

The approval of a Haematologist for use of these components is required, except DCCQ and NICU.

Issue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automatic.

FFP is given primarily for two indications: To prevent bleeding (prophylaxis) To stop bleeding (therapeutic)

Prophylactic transfusions are mainly used prior to surgery or invasive procedures. Many possible indications in patients without major bleeding are not substantiated by robust trial data (British Society of Haematology Guidelines, 2018).

FFP is not to be given for reversal of Warfarin. Use Prothrombin Complex Concentrate (Octaplex®)

Background - CoagulopathyCoagulopathy occurs in many medical and surgical illnesses, for example:

Massive blood loss Disseminated Intravascular Coagulopathy (DIC)

Requirements for issuing FFP and Cryoprecipitate Abnormal coagulation results and haemorrhage Consider the need for fibrinogen estimation in significant haemorrhage cases and where there may

be DIC such as meningococcal septicaemia Risk of haemorrhage and abnormal coagulation - such as before a procedure or to prevent further

bleeding when coagulopathy cannot be fully reversed Examples include preventing further bleeding in liver disease patients with a recent intracranial

bleed Repeat coagulation screen is indicated to see if the FFP has corrected the abnormal coagulation

before starting invasive procedures

See Indication codes Appendix 1

Remember patients born after 1st January 1996 or unknown, and/or plasma exchange will be issued OctaplasLG® in place of FFP and Methylene Blue Cryoprecipitate as per national guidance

The patient MUST have a known blood group on the laboratory system second sample rule applies as in red cells.

Group AB Plasma will be issued in an emergency where no sample is available Dose 15ml /kg

.

Cryoprecipitate is issued with the approval of a Consultant Haematologist

COMMON – acquired hypofibrinogenaemia as seen in DIC, massive bleedingo where the patient is bleedingo after use of FFP / platelets

Very RARE – inherited dysfibrinogenaemiao Where the patient is bleedingo Before a procedure likely to cause a bleed


Issue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automatic.

See Indication codes Appendix 1

12. TRAINING REQUIREMENTS

Transfusion training forms part of the Trust’s Essential Skills and Training Requirements. This is included in the mandatory Corporate Induction and Essential Skills Updates

Staff must attend a classroom based, face-to-face ‘Blood Awareness Update’ every two years This training is recorded on the individuals ESR (Electronic Staff Record) and is indicated on

the Matrix when training is due The Learning and Development Team provide compliance updates to managers in clinical

areas Compliance is further monitored through the CSC performance reviews with the Executive

Team There is a Trust Competency for preparing and administering blood or blood components.

Staff must be assessed by a level three assessor and have this signed to a minimum of level two

Staff do not need to be reassessed if practicing transfusion within a one year period

13. REFERENCES AND ASSOCIATED DOCUMENTATION

Annual SHOT Report

Blood Safety and Quality Regulations (BSQR) 2005

NICE Guidelines (NG24) November 2016

BSH Guidelines

PHT Speciality Guidelines and Policies, WRTS Blood Administration: Adults on

Haemodialysis/Haemofiltration

PHT Consent to Examination and Treatment Policy

PHT Blood Sampling Policy (Adults)

PHT Policy on Patients Who Wish to Decline Transfusions

PHT Neonatal / Paediatric Guidelines

PHT Massive Transfusion (Haemorrhage) Guideline

PHT Patient Identification Policy

PHT Drug Therapy Guideline No 161.00 Issued: 25.01.13 Use of OctaplasLG®

British Committee for Standards in Haematology (2012). Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. British Journal of Haematology, 160, 445-46

British Committee for Standards in Haematology (2012). Guideline on the administration of Blood Components

British Committee for Standards in Haematology (2015). A practical guideline for the haematological

management of major haemorrhage. British Journal of Haematology, 170, 788-803

British Committee for Standards in Haematology (2016). Draft guidelines for the use of platelet

transfusions


British Society of Gastroenterology (2015). UK guidelines on the management of variceal haemorrhage in cirrhotic patients. GUT, 0, 1-25

British Society of Gastroenterology, Clinical Services, Care Bundles. British Society of Gastroenterology & British Association for the study of the Liver Decompensated Cirrhosis Care Bundle – First 24 Hours.www.bsg.org.uk

British Society of Haematology (2018) Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding https://doi.org/10.1111/bjh.15167

European Society of Anaesthesiology Guidelines (2013). Management of severe perioperative bleeding

Royal College of Obstetricians & Gynaecologists (2015). Blood Transfusion in Obstetrics. Green-top Guideline No 47

National Blood Transfusion Committee Indication Codes – An Audit Tool (June 2016)

14. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together….for Patientswith Compassionas One TeamAlways Improving

This policy should be read and implemented with the Trust Values in mind at all times.

15. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be

monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations


100% transfusion samples taken and labelled as per policy

Phlebotomy Trainer

Spot checks Annually Policy audit report to:

HTC

HTC Chair and TP

Requests for transfusion to be made appropriately

Transfusion Lab

Manager

Audit Annually Policy audit report to:

HTC

TLM

Policy for administration of all transfusions is followed

TP Audit Quarterly Policy audit report to:

HTCTP / TPE

100% of staff involved in the process are competent

TP ESR records held by L&D and signed competency

2 yearly Policy audit report to:

HTCTP/TPE

This document will be monitored to ensure it is effective and to assure compliance

APPENDIX 1: Indication Codes for Transfusion

INDICATION CODES FOR TRANSFUSION

The indications for transfusion provided below are taken from national guidelines for the use of blood components in adults (see references). Amalgamation into this summary document aims to act as a prompt for clinicians to facilitate appropriate use and to enable robust documentation of indications.

Each indication has been assigned a number, to permit reproducible coding, when requesting blood or for documentation purposes. Specific details regarding the patient’s diagnosis and any relevant procedures to be undertaken should also be provided at request either on a written request form, electronic blood order or by telephone when the request is urgent.

These are current guidelines and may change depending on new evidence. R5b, R7a and R7b are specific to PHT

Red cell concentrates

Dose - in the absence of active bleeding, use the minimum number of units required to achieve a target Hb. Consider the size of the patient; assume an increment of 10g/L per unit for an average 70 kg adult.


R1 Acute Bleeding: Acute blood loss with haemodynamic instability. After normovolaemia has been achieved/maintained, frequent measurement of Hb (including near patient testing) should be used to guide the use of red cell transfusion – see suggested thresholds below.

R2 Hb ≤ 70g/L stable patient: Acute anaemia. Use an Hb threshold of 70g/L and a target Hb of 70-90g/L to guide red cell transfusion. Follow local/specific protocols for indications such as post cardiac surgery, traumatic brain injury, and acute cerebral ischaemia.

R3 Hb ≤ 80g/L if cardiovascular disease: Use an Hb threshold of 80g/L and a target Hb of 80-100g/L.

R4 Chronic transfusion dependent anaemia: Transfuse to maintain an Hb which prevents symptoms. Suggest an Hb threshold of 80g/L initially and adjust as required. Haemoglobinopathy patients require individualised Hb thresholds depending on age and diagnosis.

R5a Radiotherapy maintain Hb > 110g/L: There is limited evidence for maintaining an Hb of 110g/L in patients receiving radiotherapy for cervical and possibly other tumours.

R5b Radiotherapy Squamous Cell Carcinoma (Head & Neck/Gynae only) Hb > 115g/L (PHT)

R6 Exchange transfusion

R7a Orthogeriatric # NOF Hb ≤ 90g/L (PHT)

R7b Orthogeriatric # NOF Hb ≤ 100g/L if cardiovascular disease (PHT)

Platelet concentrates

Dose – for prophylaxis, do not routinely transfuse more than 1 adult therapeutic dose. Prior to invasive procedure or to treat bleeding, consider the size of the patient, previous increments and the target count.

Prophylactic platelet transfusion

P1 Plt <10 x 10*9/L reversible bone marrow failure. Not indicated in chronic bone marrow failure

P2 Plt 10 - 20 x 10*9/L sepsis / haemostatic abnormality

Prior to invasive procedure or surgery

P3 To prevent bleeding associated with invasive procedures. Transfuse platelets if:-

• P3a Plt <20 x 10*9/L central venous line

• P3b Plt <40 x 10*9/L pre lumbar puncture/spinal anaesthesia

• P3c Plt <50 x 10*9/L pre liver biopsy / major surgery

• P3d Plt <80 x 10*9/L epidural anaesthesia

• P3e Plt <100 x 10*9/L pre critical site surgery eg CNS

Transfusion prior to bone marrow biopsy is not required

P4 Therapeutic use to treat bleeding (WHO bleeding grade 2 or above, see appendix ix, page 38

• P4a Major haemorrhage Plt <50 x 10*9/L

• P4b Critical site bleeding eg CNS / traumatic brain injury Plt < 100 x 10*9/L

• P4c Clinically significant bleeding Plt < 30 x 10*9/L


P5 Specific clinical conditions

• P5a Disseminated Intravascular Coagulation (DIC) pre procedure or if bleeding

• P5b Primary immune thrombocytopenia (emergency treatment pre-procedure/severe bleeding)

P6 Platelet dysfunction

• P6a Consider if critical bleeding on anti-platelet medication

• P6b Inherited platelet disorders directed by specialist in haemostasis

Fresh frozen plasma

Dose - 15 ml/kg body weight, often equivalent to 4 units in adults.

F1 Major haemorrhage: Early infusion of FFP is recommended in a ratio of 1 unit FFP: to 1 unit red cells for trauma and at least 1 unit FFP: 2 unit’s red cells in other major haemorrhage settings. Once bleeding is under control, FFP use should be guided by timely tests for coagulation as indicated below.

F2 PT Ratio/INR > 1.5 with bleeding: Clinically significant bleeding without major haemorrhage. FFP required if coagulopathy. Aim for a PT and APTT ratio of < 1.5.

F3 PT Ratio INR >1.5 and pre-procedure: Prophylactic use when coagulation results are abnormal e.g. Disseminated Intravascular Coagulation (DIC) and invasive procedure is planned with risk of clinically significant bleeding.

F4 Liver disease with PT Ratio/INR > 2 and pre-procedure: FFP should not be routinely administered to non-bleeding patients or before invasive procedures when the PT ratio/INR is ≤ 2.

F5 TTP/plasma exchange

F6 Replacement of single coagulation factor

Prothrombin complex concentrate

Dose should be determined by the situation and INR. Local guidelines should be followed.

PCC1 Emergency reversal of vitamin K antagonists (VKA) for severe bleeding or head injury with suspected intracerebral haemorrhage.

PCC2 Emergency reversal of VKA pre emergency surgery

Cryoprecipitate

Dose – 2 pooled units, equivalent to 10 individual units, will increase fibrinogen by approximately 1g/L.

Cryoprecipitate is usually used with FFP unless there is an isolated deficiency of fibrinogen.

C1 Clinically significant bleeding and fibrinogen <1.5g/L (<2g/L in obstetric bleeding)

C2 Fibrinogen <1g/L and pre procedure

C3 Bleeding associated with thrombolytic therapy


C4 Inherited hypofibrinogenaemia, fibrinogen concentrate not available

APPENDIX 2: Blood Transfusion, Size Matters!


Version 3 – October 2016


(SHOT Report, 2016)

APPENDIX 3: Consent for Transfusion

Available to order from Medical Illustration ref: 16-0765


APPENDIX 4: Written Instruction

Written Instruction: Side One


Written Instruction: Side Two

APPENDIX iv


APPENDIX 5: Blood Component Specific Requirements

Blood Component Specific Requirements

Transfusion associated graft versus host disease (TA-GvHD) is a rare but serious complication of blood transfusion caused by lymphocytes which may be present in donor blood. Mature donor T cells recognise alloantigen’s in the recipient and become activated leading to cytokine production and lymphocyte proliferation. Inflammation and tissue damage follow.The risk associated with an individual transfusion depends on the number and viability of contaminating lymphocytes, the susceptibility of the patient’s immune system to their engraftment and the degree of immunological (HLA) disparity between donor and patient. Gamma-irradiation of blood prevents lymphocytes dividing and causing harm.The Clinician must notify the Transfusion Laboratory that the patient has specific requirements via letter on EPRO and indicate this on any transfusion request form.

Indications for Irradiated blood components: Patients receiving transfusions from first or second-degree relatives, even if patient is

immunocompetent All HLA selected platelets are irradiated Patients with inherited deficiencies in immunity which compromises T lymphocyte function (except

chronic mucotaneous candidiasis) Hodgkin’s disease patients Patients who have received treatment with purine analogues e.g. fludarabine, cladrabine,

clofaribine, bendamustine and pentostatin Patients who have received treatment with alemtuzumab and ATG Patients who have had an allogeneic haematopoietic stem cell transplant until GVHD prophylaxis is

completed and / or lymphocyte count greater than 1 x 109/l Patients undergoing autologous haematopoietic stem cell transplant. Irradiation should be

commenced 7 days prior to HPC harvesting to prevent collection of viable allogeneic lymphocytes, which cause TA-GvHD after reinfusion. Irradiated components are continued for 3 months or 6 months if the patient received total body irradiation

Patients not at risk Solid organ transplant – TA-GvHD has been documented in recipients of liver, lung and kidney

transplants but this is ordinarily associated with the transfer of donor lymphoid tissue with the graft HIV Solid tumours Non-Hodgkin’s lymphoma – currently under review by BSH

It is essential that ALL patients requiring irradiated blood components are informed of this fact, provided a card and an information leaflet – Information for patients needing irradiated blood, supplies available. See below for example of card. Patients should be advised to carry this with them at all times

Cytomegalovirus (CMV) negative components:


CMV is widespread in the population but infections are rarely problematic in the immunocompetent population. However, it has been associated with serious morbidity in vulnerable patients. The risk of transmission via transfusion has been reduced due to the process of leucocyte depletion. However, there are still occasions where it is recommended to use CMV negative components.

Indications for CMV negative components: Patients presenting with a haematological malignancy in which haematopoietic stem cell transplant

is a possible future therapeutic option pending the result of their CMV antibody status Pregnant women who are CMV negative or in whom their status is unknown Patients who have had an autologous haematopoietic stem cell transplant within the previous 6

months Patients who have had an allogeneic haematopoietic stem cell transplant Patients who are HIV positive and whom are CMV negative Patients who have received treatment with alemtuzumab


APPENDIX 6: Emergency Blood Issue

Emergency Blood Issue

Call 4444

When a massive haemorrhage is called blood and blood components will be issued according to the ‘Massive Transfusion (Haemorrhage) Guideline’ (available on the Trust Intranet) as below

O Pos blood will be issued for male patients (over 18 yrs) and older females > 55yrs (over potential childbearing years).


RBCs FFP Plats Cryo

Pack A4 4 1 ------

Pack B4 4 1 2

APPENDIX 7: Acute Transfusion Reactions (ATR)


APPENDIX 8: Common Complications Associated with Transfusion of a Blood Component

Common Complications Associated with Transfusion of a Blood Component

Problem Likely Cause Timing of Event Severity Management and Prevention

(A) Acute EventIntravascular Haemolysis

Major ABO incompatibility

Almost immediately following start of transfusion

Potentially fatal 10% MortalityCheck for DIC and renal failureMaintain BP and renal perfusionContact: On-call Haematologist, T P, Transfusion LaboratoryInitiate RED Safety Learning Event report (Datix)

TACO (Transfusion Associated Circulatory Overload)

Rapidly infused, large volume infusions or high TACO risk patients

Occurs usually within 2 - 6 hours of transfusion

Potentially fatal Accurate assessment of patients at risk of TACOCareful attention to fluid balanceConsider appropriateness of transfusionConsider rate of transfusion and diuretic coverInitiate AMBER Safety Learning Event report (Datix)

TRALI (Transfusion Related Acute Lung Injury)

Leucocyte Antibodies in donor blood

During or within 6 hours of transfusion – RARE but can be confused with ARDS (Acute Respiratory Distress Syndrome)

Potentially fatal Manage as for ARDS refer to Critical Care TeamChest X-Ray – shows bilateral pulmonary infiltratesInitiate AMBER Safety Learning Event report (Datix)

TAD (Transfusion Associated Dyspnoea)

Transfusion of donor blood and patient co-morbidities

Respiratory distress within 24 hours of transfusion and no other associated cause

Potentially fatal Assess respiratory distressCXROxygen saturations and ABG’sInitiate Safety Learning Event report (Datix) grade appropriately

Anaphylaxis IgA Antibodies in donor or recipient

Immediate Potentially fatal Maintain ABC’s and follow Anaphylaxis PolicyInitiate Safety Learning Event report (Datix) grade appropriately

Septic Shock Bacterial contamination

During transfusion

Potentially fatal Manage septicemiaInitiate Safety Learning Event report (Datix) grade appropriately


Febrile, Non-haemolytic

Anti-leucocyte antibodies

Up to several hours post transfusion

Unpleasant but not usually life threatening

Treat with Anti-pyretic (e.g. Paracetamol 1g)Initiate Safety Learning Event report (Datix) grade appropriately

Urticaria IgE Antibodies in donor blood

During transfusion

Unpleasant but not usually life threatening

Treat or prevent with Antihistamine (Oral or IV)Initiate Safety Learning Event report (Datix)grade appropriately

Delayed Event

Delayed haemolytic reaction

IgG Antibodies to donor blood

2 – 26 days post transfusion

Not usually life threatening

Poor response to transfusionJaundiceSend samples for investigationReview transfusion needs

TA-GvHD (Transfusion Associated Graft Versus Host Disease)

Donor lymphocytes

Extremely rare up to 30 days following transfusion

Usually fatal

None seen in the last 10 years following leucocyte depletionIrradiated blood to ‘at risk’ groups

Post Transfusion Purpura (PTP)

Recipient antibodies against HPA system

5 – 12 days post transfusion

Rare but treatable

Contact Bloodbank to arrange patient investigation at platelet laboratory

Post Transfusion Viral Infection

Infected donor blood

Post transfusion Rare Depends on virusSeek specialist medical advice

Iron overload Multi-transfused patients

Occurs either with single episode of multi-units or long term transfusion therapies

Rare but treatable if diagnosed

Use iron chelation therapy or venesectionMonitor LFT’s and cardiac enzymesConsider cardiac scans


APPENDIX 9: Modified WHO Bleeding Score

Modified World Health Organization Bleeding Score

Grade

Type of Bleeding

1a Visual impairment is defined as a field deficit, and patients with suspected visual impairment require an ophthalmological consultation

1 Petechiae/purpura that is localized to 1 or 2 dependent sites, or is sparse/non-confluent

Oropharyngeal bleeding, epistaxis<30 min duration2 Melaena, haematemesis, haemoptysis, fresh blood in stool, musculoskeletal

bleeding, or soft tissue bleeding not requiring red cell transfusion within 24 h of onset and without haemodynamic instability

Profuse epistaxis or oropharyngeal bleeding >30 min Symptomatic oral blood blisters, i.e. bleeding or causing major discomfort Multiple bruises, each >2 cm or any one >10 cm Petechiae/purpura that is diffuse Visible blood in urine Abnormal bleeding from invasive or procedure sites Unexpected vaginal bleeding saturating more than 2 pads with blood in a 24-

h period Bleeding in cavity fluids evident macroscopically Retinal haemorrhage without visual impairment

3 Bleeding requiring red cell transfusion specifically for support of bleeding within 24 h of onset and without haemodynamic instability

Bleeding in body cavity fluids grossly visible Cerebral bleeding noted on computed tomography (CT) without neurological

signs and symptoms4 Debilitating bleeding including retinal bleeding and visual impairment

Non-fatal cerebral bleeding with neurological signs and symptoms Bleeding associated with haemodynamic instability (hypotension, >30 mmHg

change in systolic or diastolic blood pressure) Fatal bleeding from any source


EQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the appropriate

committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Transfusion Policy (Adult)

Date of Assessment 06/07/2018 Responsible Department

HTC

Name of person completing assessment

Kay Heron Job Title Transfusion Practitioner

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy and Maternity No

Race No

Sex No

Religion or Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents


http://www.legislation.gov.uk/ukpga/2010/15/contents