MAXINE BOYD HOSPITAL TRANSFUSION PRACTITIONER BLOOD TRANSFUSION MAXINE BOYD HOSPITAL TRANSFUSION PRACTITIONER

HOSPITAL TRANSFUSION TEAM CONSULTANT HAEMATOLOGIST – LEAD FOR TRANSFUSION MEDICINE BLOOD BANK MANAGER HOSPITAL TRANSFUSION PRACTITIONER CHAIR HOSPITAL TRANSFUSION COMMITTEE PATHOLOGY QUALITY MANAGER

COST OF BLOOD PRODUCTS Packed Red Cells = £136.05 Fresh Frozen Plasma = £35.37 Platelets = £226.18 Cryoprecipitate = £221.38 Albumin = £20 Special requirements – additional cost

Emergency Blood Management Plan July 2004 DoH issued summary version of the ‘National Contingency Plan for Blood Shortages’ Each Trust expected to have their own EBMP based on this guidance Based on traffic light system –Trust running on green under normal circumstances In cases of shortage – some elective ops. will be cancelled – patients with greatest clinical need are prioritised

Blood Conservation Adhere to guidelines and policy including MSBOS Autologous transfusion - intra-operative cell salvage - post operative cell salvage Pre-operative assessment Education and Training Pharmaceutical alternatives e.g erythropoietin

RED CELL TRANSFUSION TRIGGERS Guidelines for the clinical use of red cell transfusions (BCSH 2001) Hb > 10g/dl – Transfusion not indicated Hb > 7-10g/dl – Transfuse only if clinically indicated Hb < 7g/dl – Transfusion generally indicated

Red Cell Transfusion Triggers cont….. Critical Care: transfuse to maintain Hb >7 g/dl Post-chemotherapy: transfusion threshold of 8 or 9 g/dl Radiotherapy: transfuse to maintain Hb above 10 g/dl Chronic anaemia: Transfuse to maintain Hb just above lowest conc. not associated with symptoms of anaemia (usually patients asymptomatic with Hb >8 g/dl)

Indications for Transfusion Platelets (BCSH, 2004) To prevent spontaneous bleeding when the platelet count <10 x 109/l To prevent spontaneous bleeding when the platelet count <20 x 109/l in the presence of additional risk factors such as sepsis or haemostatic abnormalities To prevent bleeding associated with invasive procedures

Platelets cont… Massive blood transfusion Bleeding, not surgically correctable and associated acquired platelet dysfunction Acute disseminated intravascular coagulation (DIC) in the presence of bleeding and thrombocytopenia Inherited platelet dysfunction with bleeding or as prophylaxis before surgery

Indications for Transfusion Fresh Frozen Plasma (BCSH 2004) Replacement of single coagulation factor deficiencies where a specific or combined factor concentrate is unavailable Immediate reversal of warfarin effect in the presence of life threatening bleeding Acute DIC in the presence of bleeding and abnormal coagulation results TTP in conjunction with plasma exchange Massive transfusion and surgical bleeding

Indications for Transfusion Cryoprecipitate (BCSH, 2004) Acute DIC where there is bleeding and fibrinogen level <1g/l Bleeding associated with thrombolytic therapy causing hypofibrinogenaemia Hypofibrinogenaemia 2o to massive transfusion

SPECIAL REQUIREMENTS Irradiated CMV negative Antigen negative Washed

Massive blood loss Aim of treatment: - restore adequate blood volume - maintain blood composition within safe limits Stem bleeding surgically Use RBC’s, crystalloids / colloids to maintain BP / BV / HB >7g/dl Priority is for bleeding to be stemmed surgically. When blood loss has slowed to 0.5l per hour or less – correct haemostatic abnormalities using other blood products.

Massive Transfusion Guidelines Acute blood loss – Guidelines for clinical use of red cell transfusions (BCSH, 2001) Maintain circulating blood volume and Hb conc. >7g/dl in otherwise fit patients & >9g/dl in older patients and those with known cardiovascular disease 15-30% loss of blood volume (800-1500ml in an adult): transfuse crystalloids or synthetic colloids. Red cell transfusion is unlikely to be necessary. 30-40% loss of blood volume (1500-2000ml in an adult): rapid volume replacement is required with crystalloids or synthetic colloids. Red cell transfusion will probably be required to maintain recommended Hb levels. >40% loss of blood volume (>2000ml in an adult): rapid volume replacement including red cell transfusion is required.

Massive bleed procedure Administer crystalloids / colloids until 1500ml loss of blood Inform blood bank – degree of urgency Samples collected for crossmatching, FBC, clotting, biochemistry. Blood bank should be informed of the situation & need for blood products immediately. Always inform them of degree of urgency. REMEMBER: the service they provide is only as good as the information they are given. Make sure all samples delivered to blood bank – never use tube. BHH – rapid carrier porter – indicate location of samples to be collected & delivered. Porter will remain connection with blood bank until no longer required. Solihull – no rapid carrier porter but system works if told urgent porter required. OOH – blood courier must always be told degree of urgency. Taxis must never be used to transport samples / blood.

X-matched blood available after 40 mins. 2 x O Rh (D) negative units available - always inform blood bank ABO Rh (D) group specific blood available 10 mins. after sample arrives in blood bank Medical staff must accept full responsibility for administration of un-crossmatched blood X-matched blood available after 40 mins. Monitor FBC & clotting (inc. fibrinogen) to guide blood component therapy All patients must have a unique ID number and be wearing a wristband. Flying squad O Rh (D) negative units – if used always inform blood bank so they can replace them and update their records. Use of GMO blood medical decision which should be made by the most senior doctor present. Switch from O Rh (D) neg. to group specific ASAP – prevent depletion of O neg. blood in blood bank. Transfuse this until crossmatch compatible blood available (40 mins.) >1 blood volume – exclude ABO mismatches by checking group of blood bags Continuous communication with the blood bank is essential to provide updates on the patient’s condition and further requirements.

Taking Blood Samples Only 1 patient at a time. Identify the correct patient. Confirm identification. First name. Surname. Address. Date of birth. Check the wristband with the request form.

Taking Blood Samples Take the blood. At the bedside label the sample bottle,using ink First name Surname DOB Hospital Registration Number (or casualty no.) Date Signature of person taking blood

DO NOT! Do not ask someone else to label the sample. Do not label the sample prior to phlebotomy. Do not leave the bedside until you have labelled the sample tube. Do not use pre-printed labels to label the sample tube. Do not use the form details to label the sample tube.

PRESCRIBING Prescription chart must contain: - Full patient identification details i.e full name, date of birth, hospital number Must specify: - Blood product to be administered, quantity, duration and special instructions

Serious Adverse Reactions Stop transfusion immediately Take down blood product / giving set Maintain IV access with infusion of 0.9% sodium chloride Treat patient Inform Blood Bank

Adverse reaction cont… Investigation Send to Blood Bank: The unit of blood Samples stated on transfusion reaction form Complete adverse reaction report (from blood bank)

Incident Reporting An incident form will be completed for all adverse reactions and for any events which delay the patients treatment. An incident form will be completed for any practice that contravenes this policy. All incidents will be graded and investigated in line with the Trust Incident Reporting Policy. All incidents occurring during the blood transfusion process, regardless of where it happens, must be reported to the blood bank manager.

BLOOD TRANSFUSION CAN KILL SHOT (Serious Hazards of Transfusion) A confidential, anonymised, UK wide scheme that aims to collect data on adverse events of transfusion of blood and blood products

SHOT Serious Hazards of Transfusion