Blood Transfusion Guidelines in Clinical Practice Salwa Hindawi MSc, FRCPath, CTM Medical Director of Blood Transfusion Services KAUH 26th July2008 Dr. Salwa Hindawi

Introduction Blood Transfusion is not without hazards you should weigh the risk against benefit use of right products to the right patient at the right time Dr. Salwa Hindawi

Donor Patient The risks associated with transfusion can be reduced by: - Effective blood donor selection. - Screening for TTI in the blood donor population. high quality blood grouping, compatibility testing. - Component separation and storage. - Appropriate clinical use of blood and blood products. - Quality assurance Dr. Salwa Hindawi

Optimal additive solution Platelets rich plasma Platelets concentrate 2nd centrifugation Whole blood Whole blood Whole blood 1stcentrifugation FFP for clinical use Red Cell concentrate Fresh plasma FFP for fractionation Optimal additive solution Cryoprecipitate Red cells in OAS Dr. Salwa Hindawi

Plasma & Cryoprecipitate ABO Selection of Blood Components Patient ABO Type RBCs, Platelets Plasma &  Cryoprecipitate O  O, A, B, AB A A,O A,AB B B,O B,AB AB AB,A,B,O Dr. Salwa Hindawi

Principles of Clinical Transfusion Practices Avoid blood transfusion Transfusion is only one part of the patient’s management. Prevention and early diagnosis and treatment of Anemia & underlying condition Use of alternative to transfusion. eg. IV fluids Good anesthetic and surgical management to minimized blood loss. Dr. Salwa Hindawi

Prescribing should be based on national guidelines on the clinical use of blood taking individual patient needs into account. Hb level should not be the sole deciding Factor Clinical evaluation is important Dr. Salwa Hindawi

Consent form to be obtained from the patient before transfusion. The clinician should record the reason for transfusion clearly. A trained person should monitor the transfused patient and if any adverse effects occur respond immediately. Dr. Salwa Hindawi

Informed consent Patient should be informed that transfusion of blood or blood component is a possible element of the planned medical or surgical intervention patient should be informed about the risks, benefits and available alternative Consent form is a doctor responsibility Dr. Salwa Hindawi

WHEN WE SHOULD TRANSFUSE BLOOD ? & WHAT BLOOD COMPONENT SHOULD BE TRANSFUSED ? Dr. Salwa Hindawi

TO TRANSFUSE BLOOD WHEN NECESSARY Dr. Salwa Hindawi

Triggers of Component Transfusion The lowest threshold for transfusion of components are: Hb level of 6-7g/dl. FFP threshold PT & PTT 1.5 times the upper limit of the normal range. Platelet threshold of: 10 000/µl- 20 000/µl for prophylactic transfusion. Consider: Clinical judgment Dr. Salwa Hindawi

Invasive or surgical procedures: 20 000/µl for BMA and Biopsy 50 000/µl for surgery, massive transfusion, Liver cirrhosis. 100 000/µl for surgery to brain or eye. American Society of clinical Oncology guidline,1996&2001. Williamson LM. Transfusion Trigger in the UK. Vox sang 2002. AABB Technical Manual 14th ed, 2002. Dr. Salwa Hindawi

Administration of blood components Pretransfusion : Recipient identification: The name and identification number on the patient’s identification band must be identical with the name and number attached to the unit. Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit (if not the same as the latter) must agree. Dr. Salwa Hindawi

Guidelines for blood component therapy Indications NB: Hb should not be the sole deciding factor for transfusion. Haemoglobin (Hb) trigger for transfusion If there are signs or symptoms of impaired oxygen transport Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available e.g. sickle cell disease or iron deficiency anemia < 7 g/dL Preoperative and for surgery associated with major blood loss. < 7 – 8 g/dL In a patient on chronic transfusion regimen or during marrow suppressive therapy. May be appropriate to control anaemia-related symptoms. < 9 g/dL Not likely to be appropriate unless there are specific indications. Acute blood loss >30-40% of total blood volume. < 10 g/dL Dr. Salwa Hindawi

Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age: 1. Hemoglobin <7 g/dL with low reticulocyte count and symptoms of anemia 2. Hemoglobin <10 g/dL with an infant On <35% hood O2 On O2 by nasal cannula On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H2O Significant apnea or bradycardia Significant tachycardia or tachypnea Low weight gain 3. Hemoglobin <12 g/dL with an infant On >35% hood O2 On CPAP/IMV with mean airway pressure 6 to 8 cm H2O 4. Hemoglobin <15 g/dL with an infant On extracorporeal membrane oxygenation (ECMO) Congenital cyanotic heart disease Dr. Salwa Hindawi

Platelet Count trigger for transfusion Indications Platelet Count trigger for transfusion As prophylaxis in bone marrow failure. < 10 x 109/L Bone marrow failure in presence of additional risk factors: fever, antibiotics, evidence of systemic haemostatic failure. < 20 x 109/L Massive haemorrhage or transfusion. In patients undergoing surgery or invasive procedures. Diffuse microvascular bleeding-DIC < 50 x 109/L Brain or eye surgery. < 100 x 109/L Appropriate when thrombocytopenia is considered a major contributory factor. Any Bleeding Patient In inherited or acquired qualitative platelete function disorders, depending on clinical features & setting. Any platelet count Dr. Salwa Hindawi

FFP trigger for transfusion Indications FFP trigger for transfusion Multiple coagulation deficiencies associated with acute DIC. Inherited deficiencies of coagulation inhibitors in patients undergoing high-risk procedures where a specific factor concentrate is unavailable. Thrombotic thrombocytopenia purpura (plasma exchange is preferred) Replacement of single factor deficiencies where a specific or combined factor concentrates is unavailable. Immediate reversal of warfarin effect in the presence or potentially life-threatening bleeding when used in addition to Vitamin K & / or Factor Concentrate (Prothrombin concentrate) The presence of bleeding and abnormal coagulation parameters following massive transfusion or cardiac bypass surgery or in patients with liver disease PT & PTT are more than 1.5 times the upper limit of normal range Cryoprecipitate trigger for transfusion Congenital or acquired fibrinogen deficiency including DIC. Hemophilia A, von Willebrand disease (if the concentrate is not available). Factor XIII deficiency. Fibrinogen< 1gm/L Dr. Salwa Hindawi

Guidelines for routine blood leucodepletion transfusion dependent patients Bone marrow transplant candidates – either autologous / peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants may be for Patients undergoing intensive chemotherapy regimens Previous repeated febrile reactions to red blood cells Guidelines for routine blood leucodepletion Intrauterine transfusion (IUT) and neonates received IUT. One week prior to stem cell collection, and for 12 months post autografting or allografting. Hodgkin’s disease Treatment with purine analogues (fludarabine, 2-CdA, deoxycofomycin) Aplastic anaemia within 6 months of ATG treatment Products obtained from close relatives or HLA matched donors. Immunodeficiency patients: congenital or acquired Guidelines for blood Irradiation (to prevent TAGVHD) Dr. Salwa Hindawi

Maximum Surgical Blood Ordering Schedule (MSBOS) MSBOS is a table of elective surgical procedures that lists the number of units of blood routinely cross-matched pre-operative. The ideal value for cross matched to transfused blood, C:T ratio is 1:1 . An acceptable value is 3:1 - 2:1 which corresponds to a blood usage of 30-50%. Dr. Salwa Hindawi

Type and Screen (T & S) an ABO and Rh type and an antibody screen and antibody identification are done when the patient is admitted. only testing necessary if low probability of transfusion Dr. Salwa Hindawi

Type and Cross (T & C) includes an ABO and Rh type and antibody screen and antibody identification. in addition includes a crossmatch where specific units of blood are held back for up to three days for a particular patient. for a high probability of transfusion. Dr. Salwa Hindawi

Crossmatch to Transfusion ratio (C:T ratio) blood is used more efficiently when the number of units set aside for a particular patient (crossmatched) are actually transfused. C:T ratio is less than 2:1 when a patient does not need blood, it is good practice to get a T& S but not a T & C Dr. Salwa Hindawi

Incompatible Blood Transfusion Clinical Setting A patient, lacking compatible blood, experiencing life- threatening, rapid blood loss or hemolysis, in whom the need for blood replacement is immediate or urgent. Dr. Salwa Hindawi

Rarely, facility may lack ABO compatible blood Rarely, facility may lack ABO compatible blood * Pan-agglutinin (autoantibody) may be present * Alloantibody to high frequency antigen may be present * Alloantibodies to multiple antigens may be present Dr. Salwa Hindawi

Guidelines for Transfusing Incompatible Red Blood Cells If patient condition permits, start the transfusion slowly at one ml per minute for the first 15 minutes. Observe the patient constantly for symptoms and signs of a reaction. Take vital signs prior to starting transfusion, whenever a reaction is suspected or, in the absence of a reaction after first 15 minutes, after 30 minutes, and after completion of transfusion. Dr. Salwa Hindawi

If there is evidence of a transfusion reaction Symptoms include fever, pain, apprehension, chills, sweating, tachycardia, or fall in blood pressure. STOP the transfusion immediately, maintaining the IV with 0.9% saline. Document vital signs at least every 15 minutes throughout the reaction. Dr. Salwa Hindawi

If patient condition warrants immediate transfusion: Begin another unit of Red Blood Cells per physician order. The new unit also is likely to test as incompatible, but may be tolerated better. If further transfusions can be delayed, follow the transfusion reaction policy and resume transfusion after evaluation is complete. Dr. Salwa Hindawi

If no symptoms or signs of transfusion reaction are noted after 30 minutes Proceed with the transfusion and monitor the patient for usual transfusion practices. Repeat the entire process for each incompatible Red Blood Cell transfused. Dr. Salwa Hindawi

Complications of Blood Transfusion Immediate Delayed HTR GVHD FNTR PTP TRALI Iron overload Bacterial Infectious contamination diseases Allergic, Anaphylaxis Dr. Salwa Hindawi

TRANSFUSION REACTION WORK-UP FORM This part should be filled by the physician incharge : Date /time : _________________________ Patient's name:_____________________ Ward : _____________________________ File number: ______________________ Number of Pregnancies/deliveries :________________ Number of previous transfusions:_______________ Diagnosis :_______________________________________________________________________________ ________________________________________________________________________________________ Transfusion time discontinued : Transfusion date/time started Temp discontinued: Temp started: Reaction noted : put  if indicated and please specify time reaction started and duration: Pruritus Hematuria Anxiety Chest Pain Pain in legs Oliguria Restlessness Chills Pain in back Anuria Headache Fever Rigor Jaundice Urticaria Sweating Bronchospasm Shock Pallor Nausea Dyspnea Cyanosis Erythema Vomiting Pulmonary edema Precordial distress Dr. Salwa Hindawi

Dr. Salwa Hindawi This part for blood transfusion services staff: URINE APPERANCE : YELLOW  RED  DARK BROWN  TURBID  SERUM PRE TRANSFUSION APPEARANCE: CLEAR  HEMOLYSIS  ICTERIC  SERUM POST TRANSFUSION APPEARANCE: CLEAR  HEMOLYSIS  ICTERIC  Blood CULTURE IF INDICATED : NEGATIVE  POSITIVE  ___________________________________ Patient’s sample and donor unit are correctly identified.  Yes  No Amount of blood was transfused : unit # ___________ volume: ____ML unit # _________ volume: ____ML Anti body screening CC DCT ABO/Rh B cell A1 cell Anti-D Anti-AB Anti- B A Patient sample Sc3 Sc2 Sc1 AG 37 RT Pre transfusion sample Immediate post transfusion sample 2nd post transfusion sample ( if possible ) Elution result:___________________________________________________________________________ Antibody identification :____________________________________________________________________ Interp cross match Cross matching CC AHG 37 IS Pre transfusion sample and unit number:___________________ Post transfusion sample and unit number:___________________ post transfusion sample and unit number:___________________ Dr. Salwa Hindawi

ALTERNATIVES TO BLOOD TRANSFUSION CRYSTALLOID SOLUTIONS COLLOID SLOUTIONS DRUGS: DDAVP BLOOD SUBSTITUTES: EPO Dr. Salwa Hindawi

AUTOLOGUS BLOOD TRANSFUSION 1- Preoperative Collection (PAD) 2-Acute normovolemic haemodilution (ANH). 3- Red Cell salvage Dr. Salwa Hindawi

Table 1. Autologous Blood Donation   Disadvantages: Advantages:   1.  Does not affect risk of bacterial Contamination. 2.  Does not affect risk of ABO incompatibility  3.  Is more costly than allogenic blood.  4.  Results in wastage of blood not transfused.   5.  Increase prevalence of adverse reactions to autologous donation.   6. Can  subject patients to perioperative anaemia and increased likelihood of transfusion.  1. Prevents transfusion-transmitted disease.  2.  Prevents red cell alloimmunization.  3.  Supplements the blood supply.  4.   Provides compatible blood for patients with alloantibodies.   5.  Prevents some adverse transfusion reaction.   6.  Provides reassurance to patients concerned about blood risks.   7.  Is acceptable to many Jehovah’s witnesses.  Dr. Salwa Hindawi

Nowing is not enough we must apply. Willing is not enough we must do. Johann Von Goethe Dr. Salwa Hindawi

Thanks Dr. Salwa Hindawi