Blood Transfusion Dr Dupe Elebute MD, MRCP, MRCPath Consultant in Haematology and Transfusion Medicine

Objectives Blood components Ordering blood & MSBOS Risks of blood therapy Adverse reactions Massive blood transfusion

Blood - Where From? Use carefully! Human source - no synthetics yet - not risk free Scarce resource 1 donor can give 1 unit every 4 months Need 10,000 units of blood/day in U.K. Use carefully!

When To Use Blood? Balance between benefits vs risks Doctor’s decision Definite indication must be recorded in the patient’s medical records Correct anaemia pre-operatively Try to reduce unnecessary exposure to blood products

Blood components Unpaid, volunteer donor Pooled products Single donations by apheresis

Blood donors Medical selection process to protect both recipients and donors Minimum age: 17 years Maximum age: 70 years (60 for first time donations) Donor deferral system

Blood donations Tested in the UK for: Hepatitis B, C HIV-I, II Syphilis ABO and RhD blood group ?vCJD  universal leucodepletion

Blood components available in the UK

Preparation of Blood Components

Blood components issued in the UK (2001-2002) Red cells 2,683,463 Platelets 251,451 Fresh frozen plasma 385,236 Cryoprecipitate 88,253 TOTAL 3,408,402

Red cells Whole blood (450ml; PCV 0.35-0.45) <1% used as ‘whole blood’ in UK Deficient in labile clotting factors Packed red cells (350ml; PCV 0.55-0.75) Stored at 2-6 ºC for up to 35 days 1 unit -> Hb rise by 1g/dl in adult New Hb trigger of 8g/dl

White cells (granulocytes) Very rarely used in the UK Only for severe infections in neutropenic patients unresponsive to antibiotics/antifungal Rx Transfused as ‘buffy coats’ or collected by apheresis

Platelet concentrates Adult single dose (1 pool): 300 x 109/L Stored at room temperature for up to 5 days (kept agitated) Obtained in two ways: Pooled platelets from 4-5 single donations Single donor platelets collected by cell separator machine (apheresis)

Platelet concentrates (2) Indications for platelet transfusions: Bone marrow failure (aplastic anaemia) Post chemotherapy, BMT Massive blood transfusion (dilutional) Platelet dysfunction (CABG, aspirin)

Fresh frozen plasma (FFP) Stored frozen at –30ºC for up to 1 yr Not routinely virally inactivated in UK To be sourced from USA (volunteer, non-transfused male donors) Provides replacement for most coagulation factors Methylene blue FFP for neonates and children born after 1st January 1996

Fresh Frozen Plasma (2) Essential to give adequate volume Dose: 12-15ml/kg ABO compatible Definite indications only: Massive blood transfusion DIC Coagulation defect with no available factor concentrate

Cryoprecipitate Separated by freezing FFP, allowing it to thaw to 4-8ºC Re-frozen & stored at –30ºC for up to 1 yr Enriched with FVIII, vWF and fibrinogen Indications: DIC Fibrinogen deficiency

Plasma products Blood products derived by fractionation of plasma: Albumin Factor VIII concentrate Factor IX concentrate Human Ig

Ordering blood Can only be done by a registered medical doctor Weigh up advantages vs risks! Consider alternatives Take blood sample for ‘group & screen’ ABO and RhD group Screen for antibodies

ABO Blood Groups † O  B blood:

RhD Group Antibody

Blood sampling Label request form with: Label sample bottle at bedside Patient’s surname Patients first name(s) Date of birth (not age) Hospital number (or A&E number) Label sample bottle at bedside Addressograph labels must not be used

Patient identification Positively identify conscious patient by asking him/her to state their name and date of birth Check information against patient’s identification wrist band

Record in hospital notes Reason for blood transfusion Blood loss Nature of surgery Pre-transfusion Hb Number of units to be transfused Planned date (and time) of transfusion

Maximum Blood Order Schedule Pre-operative schedule of units to be cross-matched for each surgical procedure Clear guidelines in Transfusion handbook Blood sample still required 24 hours pre-op to check for antibodies Does not apply to emergencies; acute bleeding; patient known to have red cell antibodies

Risks of blood transfusion Infections: - hepatitis B, C - HIV I & II - bacteria - protozoa (malaria) - vCJD (?) Transfusion reactions Immunological reactions Getting the wrong blood!

Overview of 478 cases from SHOT report 2001-2002

Distribution of errors (n=552) from SHOT report 2001-2002

Transfusing blood Inform patient! Indication Benefits Risks Alternatives

Transfusing blood (2) Check blood!! A. Check blood pack against patient’s wrist band B. Check blood pack against pink blood bank form

The final check! Must be done at the bedside Must be done by TWO people Must NOT be done by untrained staff If any discrepancy is found: Do NOT transfuse blood Inform blood bank immediately

Adverse effects of transfusion Immunological reactions: Immediate (ABO incompatibility, TRALI) Delayed (DHTR, PTP, GvHD) Non-immunological: Immediate (Bacterial, fluid overload) Delayed (e.g. viral infections, malaria)

Transfusion Reactions Acute haemolytic: Incompatible blood; can be fatal Febrile non-haemolytic: Due to cytokines from transfused WBCs Acute bacterial infection Allergic/urticarial

Transfusion Reactions (2) Fever >38ºC Rash Rigors Acute haemolytic specific: Hypotension, loin pain, dark urine Febrile non-haemolytic specific: Urticaria, pruritis

Transfusion Reactions (3) STOP the transfusion (spigot off) Using a new giving set, keep line open with normal saline Check I.D of patient, bag and cross-match form Refer to handbook for further management

Massive blood loss Any blood loss >2L (SGH) Medical emergency Usually occurs in A&E, operating theatre or obstetric department High morbidity & mortality from: Underlying cause of haemorrhage Pre-existing disease (liver, renal) Complications of massive blood transfusion

Massive Blood Loss (2) Ensure adequate venous access Attempt to maintain blood volume with saline/plasma expanders Inform blood bank Send 2 group & X-match samples If ‘flying squad’ blood used, inform BB

Massive Blood Loss (3) Call Blood Bank for : “Code Red” “Code Blue” - Obstetric patients Necessary blood products issued automatically Haematology SpR will co-ordinate

Code Red Procedure Blood components issued: First Stage 6 units blood 1 litre FFP 2 pools platelets

Code Red Procedure (2) Second Stage 6 units blood 10 units cryo if fibrinogen <0.8g/l 2 pools platelets if count <100 x 109/L Send blood for repeat FBC, chemistry, coagulation screen

Complications of Massive Tx Hypothermia Hypokalaemia Hypocalcaemia Acidosis ARDS Monitor U & Es Calcium, arterial pH ECG, CXR