Transfusion for Medical StudentsNov 2014
Requesting blood for transfusion
• What is a group and screen test?The patient’s blood group is checked and an antibody
screen is performed on the patient’s plasma. The sample can be kept in the lab for up to 6 days and then a crossmatch can be subsequently requested
• What is a crossmatch test?The patient’s plasma is mixed with the donor’s red cells to
make sure there is compatibility. When ordering state amount, time required, urgent / routine (look at surgical blood order schedule for elective surgery)
Case 1: 27-year-old patient has a massive post-partum haemorrhage with severe hypotension
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0%1. Emergency Gp O RhD negative blood does not need to be crossmatched answer text...2. Fully crossmatched blood would take 45 mins to be made available3. If O RhD blood is given there is no need to take a crossmatch sample4. Group specific blood can be made available in 15-30 mins
ASSESS URGENCYChoose the right products
COMMUNICATEAllocate a lead to liaise with lab &
porters
AVOID ERRORSCareful bedside labelling
XM, FBC, coag screen – swiftly to lab
REQUESTING BLOOD
Group O Important antibodies may cause reaction
Valuable resource
Extreme emergency only
Group specificABO & RhD compatible
Important antibodies may cause reaction
~15mins from sample arriving
CrossmatchedFully screened for antibodies
~45-60 mins from sample arriving
Safest product if time allows
Preempt need for FFP (30mins to thaw; 12-15mL/kg = 4 units for average adult)
Preempt need for platelets
Pre transfusion testing
On receipt of the pre-transfusion sample the following steps are undertaken:•Check the historical records•Group: Identify ABO and RhD group•Screen: Check plasma for antibodies•Crossmatch: Select component
The patient’s serum or plasma can be saved for up to 6 days in case later cross-match is required
Pre transfusion testing
On receipt of the pre-transfusion sample the following steps are undertaken:•Check the historical records•Group: Identify ABO and RhD group•Screen: Check plasma for antibodies•Crossmatch: Select component
The patient’s serum or plasma can be saved for up to 6 days in case later cross-match is required
Transfusion Management of Massive HaemorrhagePatient bleeding / collapses
Ongoing severe bleeding eg: 150 mls/min and Clinical shockAdminister Tranexamic Acid
(1g bolus followed by 1g infusion over 8 hours)
Patient bleeding / collapsesOngoing severe bleeding eg: 150 mls/min and Clinical shock
Administer Tranexamic Acid(1g bolus followed by 1g infusion over 8 hours)
Call for help‘Massive Haemorrhage, Location, Specialty’Alert emergency response team (including
blood transfusion laboratory, portering/ transport staff)
Consultant involvement essential
Call for help‘Massive Haemorrhage, Location, Specialty’Alert emergency response team (including
blood transfusion laboratory, portering/ transport staff)
Consultant involvement essential
Take bloods and send to lab:XM, FBC, PT, APTT, fibrinogen, U+E, Ca2+
NPT: ABG, TEG / ROTEM if availableand
Order Massive Haemorrhage Pack 1Red cells* 4 unitsFFP 4 units
Platelets 1 dose (ATD)(*Emergency O blood, group specific blood,
XM blood depending on availability)
Take bloods and send to lab:XM, FBC, PT, APTT, fibrinogen, U+E, Ca2+
NPT: ABG, TEG / ROTEM if availableand
Order Massive Haemorrhage Pack 1Red cells* 4 unitsFFP 4 units
Platelets 1 dose (ATD)(*Emergency O blood, group specific blood,
XM blood depending on availability)
ReassessSuspected continuing haemorrhage
requiring further transfusionTake bloods and send to lab:FBC, PT, APTT, fibrinogen, U+E, Ca2+
NPT: ABG, TEG / ROTEM if available
ReassessSuspected continuing haemorrhage
requiring further transfusionTake bloods and send to lab:FBC, PT, APTT, fibrinogen, U+E, Ca2+
NPT: ABG, TEG / ROTEM if available
Give MHP 2Give MHP 2
Insert local arrangements:Activation Tel Number(s)
•Emergency O red cells- location of supply:
* Time to receive at this clinical area:•Group specific red cells
• XM red cells
Insert local arrangements:Activation Tel Number(s)
•Emergency O red cells- location of supply:
* Time to receive at this clinical area:•Group specific red cells
• XM red cells
STOP THE BLEEDING
RESUSCITATEAirway
BreathingCirculation
Haemorrhage ControlDirect pressure / tourniquet if appropriateStabilise fracturesSurgical intervention – consider damage control surgeryInterventional radiologyEndoscopic techniques
Haemorrhage ControlDirect pressure / tourniquet if appropriateStabilise fracturesSurgical intervention – consider damage control surgeryInterventional radiologyEndoscopic techniques
Haemostatic Drugs
Vit K and Prothrombin complex concentrate for warfarinisedpatients andOther haemostatic agents: discuss with Consultant Haematologist
Haemostatic Drugs
Vit K and Prothrombin complex concentrate for warfarinisedpatients andOther haemostatic agents: discuss with Consultant Haematologist
Prevent HypothermiaUse fluid warming deviceUsed forced air warming blanket
Prevent HypothermiaUse fluid warming deviceUsed forced air warming blanket
Cell salvage if available and appropriateConsider ratios of other components: 1 unit of red cells = c.250 mlssalvaged blood
Cell salvage if available and appropriateConsider ratios of other components: 1 unit of red cells = c.250 mlssalvaged blood
Consider 10 mls Calcium chloride 10% over 10 minsConsider 10 mls Calcium chloride 10% over 10 mins
2 packs cryoprecipitate if fibrinogen < 1.5g/l or as guided by TEG / ROTEM
2 packs cryoprecipitate if fibrinogen < 1.5g/l or as guided by TEG / ROTEM
Aims for therapyAim for:Hb 8-10g/dlPlatelets >75 x 109/lPT ratio < 1.5APTT ratio <1.5Fibrinogen >1.5g/lCa2+ >1 mmol/lTemp > 36oCpH > 7.35 (on ABG) Monitor for hyperkalaemia
Aims for therapyAim for:Hb 8-10g/dlPlatelets >75 x 109/lPT ratio < 1.5APTT ratio <1.5Fibrinogen >1.5g/lCa2+ >1 mmol/lTemp > 36oCpH > 7.35 (on ABG) Monitor for hyperkalaemia
STAND DOWNInform lab
Return unused components
Complete documentationIncluding audit
proforma
Transfusion lab
Consultant Haematologist
Transfusion lab
Consultant Haematologist
Thromboprophylaxis should be considered when patient stable
Give MHP 1Give MHP 1
ABG – Arterial Blood Gas APTT – Activated partial thromboplastin time ATD- Adult Therapeutic DoseFFP- Fresh Frozen plasma MHP – Massive Haemorrhage Pack NPT – Near Patient TestingPT- Prothrombin Time TEG/ROTEM- Thromboelastography XM - Crossmatch
Order Massive Haemorrhage Pack 2Red cells 4 unitsFFP 4 units
Platelets 1 dose (ATD)and subsequently
request Cryoprecipitate 2 packsif fibrinogen <1.5g/l or according to TEG /
ROTEM
Order Massive Haemorrhage Pack 2Red cells 4 unitsFFP 4 units
Platelets 1 dose (ATD)and subsequently
request Cryoprecipitate 2 packsif fibrinogen <1.5g/l or according to TEG /
ROTEM
Once MHP 2 administered, repeat bloods:FBC, PT, APTT, fibrinogen, U+E,
NPT: ABG, TEG / ROTEM if availableTo inform further blood component
requesting
Once MHP 2 administered, repeat bloods:FBC, PT, APTT, fibrinogen, U+E,
NPT: ABG, TEG / ROTEM if availableTo inform further blood component
requesting
Activate Massive Haemorrhage Pathway
Continuous cardiac monitoringContinuous cardiac monitoring
v1 2011
Recognise blood loss
Resuscitate, call for help
Stop the bleeding – TXA, PCC
Team approach
Emergency runner
Communicate with lab early and clearly
Know where the Emergency O Neg is in your Trust
Massive haemorrhage packs 1 and 2
Monitor coag tests and move to goal directed therapy
Stand down
Case 2
67-year-old male, Mr Arvind Patel, (Group O) is admitted for elective hip replacement surgery. His Hb is 100 g/L. Because of excessive bleeding on the operating table the Consultant Anaesthetist asks for 2 units of blood. The theatre nurse collects 2 units of red cells labelled for Mr Suhail Patel and starts transfusion. Mr Suhail Patel is Group B.
What are the potential clinical consequences for Mr Arvind Patel and how would they be managed?
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0% 1. There would be no problems as it is safe to give Group B blood to a Group O recipient so the transfusion could continue
2. The transfusion must be stopped immediately3. The partially transfused bag must be returned to the lab with
a blood sample from the patient 4. Oozing from venepuncture sites might be a sign of a
transfusion reaction
Blood Groups Blood Group Antibodies
A Anti-B
B Anti-A
AB None
O Anti-A Anti-B
RhD positive or RhD negative
A
OAB
B
How could the error have been avoided?
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0% 1. The theatre nurse collecting the blood should make a hand written note of the patient’s details so that she can identify the correct patient
2. The bag of blood should be checked against the patient’s notes3. The bag of blood should be checked against the patient’s wrist
band4. There is no need to do the bedside check when the patient is
anaesthetised
Could the transfusion have been avoided in the first place?
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0% 1. Yes because this type of surgery is suitable for cell salvage2. Yes because a Hb of 100g/L is a safe level for a 67 year old man3. No because the Hb alone is not the only trigger for transfusion4. Tranexamic acid would help to reduce blood loss in this situation
BLOOD“1 unit RBC”
Usual time: 3hrs
4hr limit from removal from cold storage
to end of transfusion
Blood warmer for rapid transfusions
COMMON INDICATIONS
Acute blood lossOnly with significant blood volume loss
Consider cell salvage
Anaemia Hb < 70 g/LLikely requires transfusion
Consider correctible causes
Anaemia Hb 70 - 100 g/LConsider correctible causes
Transfuse if symptoms/needs eg IHD
Pre-operative assessmentCorrection of anaemia reduces need for
transfusion
MBOS (Maximum Blood Ordering Schedule)
Refer to Trust Blood Transfusion Policy
Refer to Trust Blood Transfusion Policy
Case 3: 17-year-old female with heavy periods presents with Hb of 50 g/L and MCV 55 fl.
Would you give a blood transfusion?
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0% 1. Yes, I would give a blood transfusion – that Hb level is very low2. No, I wouldn’t give a blood transfusion because she will respond to an alternative
therapy3. Oral iron will increase the Hb by 40g in 1 week
Case 4: A full blood count states the platelet count to be ‘6 x 109/L’ with an associated peripheral blood film comment of ‘platelet clumping seen’. A prophylactic
platelet transfusion (1ATD) is indicated as the platelet count is <10 x 109/L
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1. True2. False
Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life-threatening
bleeding in patients on warfarin
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1. True2. False
Red Cells Whole Blood Platelets (also apheresis)
Plasma Fresh Frozen Plasma Cryoprecipitate
Fractionation
Factor concentrates Eg FVI I I , FI X, PCC
I mmunoglobulin Albumin (Non UK Plasma)
Blood Components
BLOOD COMPONENTS Fresh Frozen Plasma
“1 unit FFP”
Usual time: 30 mins/unitNeeds 30 mins to thaw in lab
Usual dose 12-15 mL/kg (4-6 units for average adult)
Main indications: coagulopathy with bleeding/surgery,
massive haemorrhage, TTP. Not warfarin reversal.
Cryoprecipitate“1 pool cryoprecipitate”
Usual time: 30 mins/bagNeeds 30 mins to thaw in lab
Adults: 1 pool = 5 donor units
Usual adult dose: 2 pools (10 donor units)
Main indication:
coagulopathy with fibrinogen < 1.5 g/L
Platelets“1 ATD platelets”
Usual time: 30 mins1hr limit
Usual dose: 1 adult treatment dose (ATD)
Shelf-life only 7 days from donation
Used as prophylaxis or treatment of bleeding / pre procedure in patients with
thrombocytopenia
Prothrombin Complex Concentrate (PCC)
Plasma-derivedVit K dependent factors: II VII IX X
For emergency reversal of life-threatening warfarin over-
anticoagulation(do not use FFP)
Issued by transfusion lab – supply in A&E
See trust policy
Prothrombin Complex Concentrate (PCC)
Plasma-derivedVit K dependent factors: II VII IX X
For emergency reversal of life-threatening warfarin over-
anticoagulation(do not use FFP)
Issued by transfusion lab – supply in A&E
See trust policy
PlateletsMassive haemorrhage
Keep platelet count above 75 x 109/l
Bone marrow failureplatelet count <10 × 109/l or <20 × 109/l if additional risk, e.g. sepsis
Prophylaxis for surgeryMinor procedures 50 x 109/l;More major surgery 80 x 109/l; CNS or eye surgery 100 x 109/l
Cardiopulmonary bypassPlatelets should be readily available use only if bleeding
All patients with Hodgkin’s Disease should receive irradiated blood
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1. True2. False
All patients born after 1996 should have virally inactivated, non-UK sourced Plasma
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1. True2. False
All Stem Cell Transplant / Bone marrow transplant recipients require CMV negative blood
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1. True2. False
Pregnant women have no special blood requirements, so there is no need to inform the transfusion laboratory of
their pregnancy or gestation on the request form
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1. True2. False
SPECIAL REQUIREMENTS
CMV NEGATIVE
To keep at-risk patients CMV free(~50% of us are CMV negative)
Children < 1yr
Intrauterine transfusions
Congenital immunodeficiency
and unless known to be CMV IgG +ve:
Pregnant women having elective transfusion
IRRADIATEDTo prevent transfusion-associated
graft versus host disease (rare)in specific T-cell immunodeficiency
cases
Intrauterine transfusions
Congenital immunodeficiency
Hodgkin Lymphoma
Stem cell / marrow transplant patients
After purine analogue chemo
(eg: fludarabine)
Fairly specific indications… Paeds, Haem, Onc, O&G… …but “it is the responsibility of the prescribing doctor”
Fairly specific indications… Paeds, Haem, Onc, O&G… …but “it is the responsibility of the prescribing doctor”
Refer to Trust Blood Transfusion Policy
Refer to Trust Blood Transfusion Policy
The risk of transmission of HIV with transfusion of red cells is 1 in 5 million donations in the UK
(0.2 per million donations)
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1. True2. False
A patient becomes acutely short of breath following a transfusion of FFP. Chest X-ray shows bilateral pulmonary
infiltrates and you give diuretics with some effect. The case should be reported as a clinical incident via the hospital reporting system, so it can be followed up appropriately
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1. True2. False
All donors are now screened for vCJD
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1. True2. False
A patient complains of feeling unwell during their transfusion. Their observation chart shows their
temperature, BP, pulse rate and respiratory rate to be stable. No specific action is required
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1. True2. False
A patient develops mild urticaria following a platelet transfusion. You should administer IV
chlorphenaramine (piriton) and IV hydrocortisone
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1. True2. False
Anaphylaxis is most likely to happen in the first 15 minutes of transfusion
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1. True2. False
Serious Adverse Events from blood transfusion reported in UK 1996-2011
Serious Adverse Events from blood transfusion reported in UK 1996-2011
Risk of giving wrong blood is much greater than transfusion transmitted infection
Risk of giving wrong blood is much greater than transfusion transmitted infection
TRANSFUSON REACTIONS
Suspectedsevere
reactionPyrexia, rigorsHypotension
Loin / back painIncreasing anxiety
Pain at the infusion siteRespiratory distress
Dark urineSevere tachycardia
Unexpected bleeding (DIC)
Mild reactionTemp rise < 1.5°C
UrticariaRash
Pruritis
STOP TRANSFUSION
Review obs
Paracetamol
Chlorpheniramine?
Restart cautiously
STOP TRANSFUSION
Right patient?
Right blood product?
Whole set to lab
New set with saline
Full bloods as policy
Checklist (see policy)
Incident formRefer to Trust
Blood Transfusion Policy
Refer to Trust Blood Transfusion
Policy
Trust Blood Transfusion Policy
OR
www.transfusionguidelines.org.uk
OR
Ask for help
Trust Blood Transfusion Policy
OR
www.transfusionguidelines.org.uk
OR
Ask for help
Yes
Severe / life-threatening•Call for urgent medical help•Initiate resuscitation- ABC•Discontinue transfusion and maintain venous access•Monitor the patient : TPR, BP, urinary output, oxygen sats
Anaphylaxis follow anaphylaxis pathwayIf bacterial contamination policy likely start antibiotic treatmentInform hospital transfusion departmentReturn unit and administration set to transfusionPerform appropriate investigations
Not Life threatening or Severe
Resources
Trust Guidelines and Policies
The Transfusion Handbookwww.transfusionguidelines.org.uk
Your Hospital Transfusion Team