1. Transfusion Third Year Medical Student Teaching
Friday 11th March 2016
Dr Dawn Swan – Haematology ST4 Registrar
Dr Holly Owen – Foundation Year Two
Slides by Dr Jayne Peters- Haematology ST5 Registrar

2. Overview The Journey of Blood Matching blood Team learning session
Review of answers
Summary and questions

3. The Journey of Blood Donor NHS BT Hospital Blood Bank Ward Area
Donor Screening
Arm Washing
Samples for group and viral testing
Donor
NHS BT
Hospital Blood Bank
Ward Area
Patient
Manufacturing of the components from whole blood
Store units
Cross match
Designate units and label
Prescription
Positive patient identification
Wrist band

4. Blood Collection Packs

5. Blood Components Imported plasma from non-UK source
Fresh Frozen Plasma*
Plasma
Cryoprecipitate*
Whole blood donation
Mix with citrate to stop clotting (CPD)
Buffy Coat
Granulocytes
Pooled Platelets
Plateletpheresis
Platelet dose
Red cell units*
Mix with SAG-M
(preservative)
Red cells
*Leucodepletion

6. Red Cell Groups A Anti-B B Anti-A A and B AB None O Anti-A,B
Antigen(s) presents on
red cell surface
Blood
Group
Antibodies present in donors plasma A
Anti-B B
Anti-A
A and B AB
None O
Anti-A,B

7. Cross Matching Cards ‘Reverse group’
Adding patients plasma to the two end columns:
Does the patient have anti-A?
Does the patient have anti-B?
‘Forward group’
Adding patient’s red cells to the first four columns:
Does the patient have A antigen expressed on the cell surface?
Does the patient have B antigen expressed on the cell surface?
Does the patient have D antigen expressed on the cell surface?

8. Cross Matching Cards

9. Ordering and Matching Blood
Group and Save:
Identify the patients blood group
Identify if any antibodies present
Hold the sample
Cross-match:
To issue blood
Locate the compatible red cell units
Mix small amount of patient’s plasma with donor’s red cells
No reaction? Can issue unit

10. Ordering and Matching Blood
In an emergency (major haemorrhage)
Group O negative may be issued
Stored in A+E, theatres and blood bank
Important antibodies may cause a reaction
15 minutes from sample arriving
Group specific blood (ABO and RhD compatible)
45-60 minutes from sample arriving
Fully matched and screened for antibodies

11. Team Learning:
Discuss your answers as a small group using the materials provided to help guide your decisions.

12. Red Cells
Questions 1 and 4

13. Question
Question 1:
A GP refers in an asymptomatic 30 year old female with a history of menorrhagia and a Hb 44g/L.
Initial treatment should include a 2 unit transfusion of packed red cells.
True or false?

14. Question
Question 1:
A GP refers in an asymptomatic 30 year old female with a history of menorrhagia and a Hb 44g/L.
Initial treatment should include a 2 unit transfusion of packed red cells.
True or false?

15. Question
Question 4:
An 82 year old male with known diabetes and hypertension has a repeat Hb of 101g/L following admission for recurrent chest pain.
It is appropriate to transfuse him packed red cells.
True or false?

16. Question
Question 4:
An 82 year old male with known diabetes and hypertension has a repeat Hb of 101g/L following admission for recurrent chest pain.
It is appropriate to transfuse him packed red cells.
True or false?

17. Red Cells Provided in leucodepleted ‘units’ measuring
approximately 280ml
Each unit of red cells rises the Hb by
approximately 10g/l (4mls/kg)
Transfused over 2-4 hours
Patients should receive written
information prior to receiving a
blood transfusion including the
risks of reaction and viral
transmission
Decision to transfuse should be documented
Storage:
Temperature: 4°C +/- 2°C
Shelf life: up to 35 days

18. Red Cells No universal trigger for transfusion
Decision to transfuse should be based on clinical judgement
Asymptomatic patients with chronic anaemia secondary to iron deficiency may benefit from iron replacement rather than transfusion
Always assess haemotinics if not already done so for a patient presenting in an anaemic state
Is the result in keeping with what is expected?
?dilutional or from a different patient

19. Red Cells

20. Red Cells CMFT indications for blood transfusion: R1. Acute blood loss
R2. Hb <70 g/l
R3. Hb <90 g/l in patient with known cardiovascular disease
R4. Transfuse to maintain Hb over 70g/l
R5. Post-chemotherapy (threshold Hb g/l)
R6. Radiotherapy (Maintain Hb>100 g/l)
R7. Chronic anaemia – maintain above the lowest concentration that is not associated with symptoms

21. FFP (Fresh Frozen Plasma)
Questions 2 and 6

22. Question Question 2: A 45 year old male with alcoholic liver disease
presents with gross ascites. You are asked to do a diagnostic tap, however note that the clotting
screen is abnormal;
PT 17.2 (11-14), APTT 26 (22-28). It is recommended to administer FFP prior to proceeding
True or false?

23. Question Question 2: A 45 year old male with alcoholic liver disease
presents with gross ascites. You are asked to do a diagnostic tap, however note that the clotting
screen is abnormal;
PT 17.2 (11-14), APTT 26 (22-28). It is recommended to administer FFP prior to proceeding
True or false?

24. Question
Question 6:
FFP is dosed according to patient weight. When clinically indicated, the average sized adult requires 2 units of FFP
True or false?

25. Question
Question 6:
FFP is dosed according to patient weight. When clinically indicated, the average sized adult requires 2 units of FFP
True or false?
Dose = 15mls/kg
Iml/kg will cause a 1% rise in clotting factors.

26. FFP
FFP is prepared from anticoagulated whole blood by separating and freezing to a temperature of -30°C within 6 hours of collection
The volume of a typical unit: ml
FFP contains all coagulation factors
Sample needed for transfusion lab as group specific
Storage:
Shelf life: up to 36 months frozen (24 hours at 4°C after thawing- changing to 5 days)

27. Octoplas
Octaplas is a solvent detergent treated, prion reduced human plasma product
It has standardised coagulation factors content and is available in 200 ml bags with A, B, O and AB groups
Patients born on or after 1st January 1996 should receive plasma from a country with a low risk of vCJD
This product is also used for plasma exchanges for certain diagnoses such as thrombotic thrombocytopenic purpura

28. Clinical indications for use of FFP Inappropriate use of FFP
Single coagulation factor deficiencies where clotting factor concentrate not available e.g. Factor V
Multiple coagulation factor deficiencies/DIC associated with severe bleeding
Plasma exchange for Thrombotic Thrombocytopenic Purpura (TTP)
Liver Disease (response unpredictable)
Massive Transfusion
Surgical Bleeding
Inappropriate use of FFP
Reversal of Warfarin
Vitamin K deficiency
Simple volume replacement (high risk of anaphylaxis)
Plasma exchange (except for TTP)

29. FFP

30. Cryoprecipitate Produced by thawing FFP at 4°C Contains: Factor XIII
Factor VIII
vWF
Fibrinogen
Indicated if fibrinogen
<1.5 and bleeding
Storage:
Shelf life: up to 36 months frozen (24 hours at 4°C after thawing)

31. Platelets
Questions 3, 5 and 7

32. Question Question 3: During massive haemorrhage secondary to GI
bleeding, it is advisable to keep the platelet count
above 100 x109/L?
True or false?

33. Question Question 3: During massive haemorrhage secondary to GI
bleeding, it is advisable to keep the platelet count
above 100 x109/L?
True or false?

34. Question
Question 5:
A full blood count states the platelet count to be
‘6x109/l’ with an associated peripheral blood film
comment of ‘platelet clumping seen.
A prophylactic platelet transfusion (1 ATD) is
indicated as the platelet count is <10 x109/l?
True or false?

35. Question
Question 5:
A full blood count states the platelet count to be
‘6x109/l’ with an associated peripheral blood film
comment of ‘platelet clumping seen.
A prophylactic platelet transfusion (1 ATD) is
indicated as the platelet count is <10 x109/l?
True or false?

36. Question
Question 7:
A patient with thrombocytopenia secondary to sepsis has a repeat platelet count of 70x109/L and requires neurosurgery.
You should give 1 ATD (adult treatment dose) of platelets then recheck the FBC.
True or false?

37. Question
Question 7:
A patient with thrombocytopenia secondary to sepsis has a repeat platelet count of 70x109/L and requires neurosurgery.
You should give 1 ATD (adult treatment dose) of platelets then recheck the FBC.
True or false?

38. Platelets Platelets Each ‘ATD’ – adult therapeutic dose is
‘pooled’ from 4 different platelet
donations
One ATD of platelets would be expected
to rise the platelet count by x109,
we can check this by doing a ‘1 hour
increment’
Given over 30 minutes
Storage:
Agitation
Temp: 20-24°C
Shelf life: 5 days (7 days if bacterial screening)

39. Platelets

40. Platelets Platelet Indications:
P1 – reversible bone marrow failure + count <10 X109/L
P2 - <20 with additional risk factors for bleeding
P3 –
Prevent bleeding associated with invasive procedures:
> 20 for Central Venous Catheters (CVC)
> 50 for lumbar puncture or surgery
> 80 for spinal/epidural anaesthetic
> 100 for critical surgical sites
brain, eyes, spinal cord

41. Platelets Platelet Indications:
P4 – massive blood transfusion (after 1 circulating blood volume)
P5 – acquired platelet dysfunction
P6 – acute DIC and bleeding
P7 – inherited platelet dysfunction
P8 – primary immune thrombocytopenia for emergency treatment in advance of surgery or in major haemorrhage
P9 – post-transfusion purpura in the presence of major haemorrhage
P10 – Neonatal alloimmune thrombocytopenia (bleeding or prophylaxis, maintain >30)

42. Massive Haemorrhage
What laboratory parameters would you aim for during a massive transfusion in a bleeding patient?

43. Platelets
Platelet Clumping:

44. Platelets Platelet Clumping:
If unexpected low platelet count, ask for a blood film
If platelet clumping seen, repeat the FBC using a citrate bottle (the one used for clotting)
Patients with platelet clumping do not need platelet transfusions

45. Warfarin Reversal
Question 8

46. Question
Question 8:
Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life threatening bleeding in patients on warfarin
True or false?

47. Question
Question 8:
Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life threatening bleeding in patients on warfarin
True or false?

48. Urgent Coagulation Screen
Warfarin Reversal
Urgent Coagulation Screen
PT, APTT, Fibrinogen, INR
Do not await results before administering reversal agents
Resuscitation
IV fluid resuscitation
Activate massive haemorrhage pathway
Vitamin K
Administer Vitamin K 5mg IV
Omit Warfarin!
Administer PCC
Octaplex 25units/Kg (round up to nearest 500 units)
Maximum 3000 units

49. Patients who refuse blood products
Question 9

50. Question
Question 9:
Jehovah’s Witnesses do not accept red blood cell transfusions but on the whole are happy to accept platelets or plasma
True or false?

51. Question
Question 9:
Jehovah’s Witnesses do not accept red blood cell transfusions but on the whole are happy to accept platelets or plasma
True or false?

52. Patients who refuse blood
Patients can refuse blood products for personal
reasons not only religious regions
Assess capacity to make decision
Spend time exploring the patient’s reasoning
Ideally the patient should be alone, away from influence of family/friends
Accompany with nurse specialist

53. Patients who refuse blood
Each of the products need to be addressed in turn with
explanation to the patient:
why it may be indicated
where this product is acquired from
It needs to be documented clearly whether they would
accept this product.
Jehovah’s Witnesses have an advanced directive
already written.

54. Patients who refuse blood
Nearly all patients refuse transfusion of whole blood
products:
Red cells, platelets, white cells and unfractionated plasma
Some patients will accept transfusion of blood
derivatives:
Albumin, cryoprecipitate, clotting factor concentrates and immunoglobulins
Most patients do not refuse:
Intra-operative cell salvage, apheresis, haemodialysis
Recombinant products: e.g. Epo and G-CSF
Others: IV iron and tranexamic acid

55. Summary Transfusion of blood products can save lives, before
you prescribe, ask yourself:
Does this patient need blood product support?
Are there alternatives?
Is it the correct blood product?
Is it the correct amount?
Think of the reasons behind the abnormality, how can this be investigated and managed?

56. Summary

57. Thank you for listening
Any Questions?
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