1. بسم رب نور

2. Prevention & Management of transfusion reaction
Dr.sh.sharifi
20-21 th feb 2008

3. Febrile Rxn Management
Give antipyretics (e.g. aspirin – except children – Reyes Syndrome)
Avoid aspirin in thrombocytopenic pt’s
Do not restart transfusion

4. Febrile Rxn Prevention; Antipyretics
Prestorage leukoreduced blood products

5. Allergic Rxn Management
Premedicate Pt with antihistamines (e.g. Benadryl)
If signs/symptoms mild &/or transient, restart transfusion after treatment
Do NOT restart transfusion if pulmonary symptoms/signs, fever present

6. Allergic Rxn
Prevention
Prophylactically treat with antihistamines

7. TRALI Management Steroids Aggressive ventilatory support
Hemodynamic support

8. TRALI
Prevention
Typically ,TRALI is adonor specific phenomen so donor deferred from donating plasma products.
Transfuse washed RBC’s from which plasma is removed
Platelet units can also be washed, but platelet function is significantly reduced

9. Circulatory Overload Management Slow rate of infusion
Place Pt in upright position, if possible, with feet in dependent position
Diuretics
Oxygen
Morphine (if necessary)

10. Circulatory Overload Prevention
Vigilant assesment of patients input and output
Slow rate of infusion
Pretransfusion and/or intratransfusion diuretic adminstration

11. Septic Rxn Management Obtain blood cultures from Pt
Return blood component bag(s) to blood bank for further laboratory work-up
Treat septicemia with antibiotics
Treat shock with fluids & vasopressors

12. Septic Rxn
Prevention
Collect, process, store, transport, and transfuse blood components according to contemporary standards of practice (e.g. for FDA standards adhere to cGMP’s – current good manufacturing practices – found in Code of Federal Regulations)
Transfuse blood components within 1 to 2 hrs – do not exceed 4 hrs

13. Acute Hemolytic Management Treat hypotension, renal failure, DIC, etc.
Submit blood samples for blood bank/laboratory tests
Avoid, if possible, further transfusions till work-up complete and/or Pt recovered from rxn

14. MANAGEMENT OF ACUTE HEMOLYTIC TRANSFUSION REACTION
1-Stop the transfusion and maintain intravenous access.
2-make initial rapid assessment of patient and requirements for basic and advanced support.
3-notify transfusion service,collect transfused units(full or partially),tubing,etc.,and return them to blood bank.
4-Reconfirm identity of blood units and patient.
5-collect appropriate patient blood specimens
6-pending results of initial evaluation,consider the following supportive approches:
A-IV fluid resuscitation to treat hypotension.
B-maintenance intravenous fluids at 3000 ml/m2/day with adminstration of sodium bicarbonate to keep PH>7.0

15. Continue….
C-diuretics:mannitol(20%),100 ml/m2 give over min,then 30 ml/m2/hr for text 12 hours;furosemide(adults mg;infants and children 1-2 mg/ kg to an adult dose)
D-low-dose dopamine,1-5 mcg/kg/min.
E-replacement of procoagulant factors and fibrinogen with fresh frozen plasma and cryoprecipitate and platelets with platelet concentrate.
F-heparin: u/kg,(unfractionated heparin)and infusion u/kg/hr to keep heparin level u/ml.

16. prevention The best way to prevent AHTR is to avoid transfusion
Defining clear-cut and defendable indication for transfusion
Careful determination of the Hb or HCT level for ordering TRX
patient-donor identification
Autologousblood safer than homologous

17. Serious Hazards of Transfusion Reporting Scheme
Overview of cases from 2004 Report (n=541)
SHOT is a voluntary anonymised reporting scheme, which aims to collect data on the serious adverse events of transfusion and to make recommendations to improve transfusion safety.
SHOT has demonstrated since their launch in 1996 that the biggest risk is the patient receiving an incorrect blood component (IBCT).
The general public and most staff assume that the greatest risk is ‘Transfusion Transmitted Infection’ but SHOT have shown that the risk of Transfusion Transmitted Infection (TTI) is extremely low.
Immunological conditions, e.g. Acute Transfusion Reaction (ATR), Delayed Transfusion Reaction (DTR), Post Transfusion Purpura (PTP), Transfusion Associated Graft versus Host Disease (TA-GVHD), Transfusion Related Acute Lung Injury (TRALI), are not readily preventable. However, early recognition may reduce associated morbidity.
Over the 8 year period since the SHOT scheme was launched, in the IBCT category, 18 patients have died and 91 patients suffered major morbidity definitely, probably or possibly related to the transfusion.
*Wrong blood incidents are without exception avoidable errors!*

18. Serious Hazards of Transfusion Reporting Scheme
Distribution of Errors in IBCT Category (2004 Report)
Errors have been shown to occur in every part of the transfusion process and in every clinical area, wards, theatre, accident & emergency, intensive care and outpatient clinics.
Multiple errors were implicated in around half of cases reported to SHOT since the scheme was launched. Although there was potential to pick up the error at various stages of process, the opportunity was missed. All disciplines and grades of staff from porters to doctors have been implicated in transfusion errors.
The environment has been shown to be a factor contributing to errors, e.g., lack of space to undertake checking procedures, distractions occurring during final checking procedure and transfusions taking place overnight.
Wrong blood events: Patients who received a blood component intended for a different person, or of an incorrect blood group
Inappropriate specification: Failure to provide irradiated blood components for patients treated with purine analogues or who have undergone stem cell transplantation
Pre–transfusion testing errors: Incorrect blood groups, missed alloantibodies and missed incompatibilities
Inappropriate transfusion: Full blood sample unsuitable, sample taken from drip arm, full blood results wrongly transcribed, transfusion before haematology results available
Handling errors: Failure to clear expired units from stock, failure in correct storage and delivery of components.
The aim is to always have the:Right blood, right patient, right time

19. Requesting Procedure Check the patient’s case note Transfusion history
Special requirements
e.g., irradiated, CMV negative
Complete request form or order com
The person making the request is responsible for checking the patient’s case notes for any previous transfusion history.
Any special requirements, such as irradiated or CMV negative blood, should be clearly stated on the request form.
All the relevant details on the request form or order com/electronic system (if applicable) should be completed.

20. Full Name + Date of Birth
Sampling Procedure
Step 1: Ask the patient to tell you their:
Full Name + Date of Birth
Check this information against the patient’s ID wristband
Before taking a sample for pre-transfusion testing it is vital to positively identify the patient.
Step 1: This can best be achieved by asking the patient to tell you their NAME and DOB and then check this information against the patient’s wristband for accuracy.
If you are taking a sample for pre-transfusion testing from a patient in the out patient setting where they may not be wearing a wristband, refer to your local hospital policy for advice.
In the unconscious patient (or in paediatric practice) it is imperative to verify the patient identification details with a second member of staff.
*In unidentified patients in the A/E department the unique identification number should be used at all times during the transfusion process *
Be extra vigilant when checking the identity of the unconscious / compromised patient

21. Sampling Procedure Step 2: Check the patient’s ID
EXAMPLE REQUEST FORM
Step 2: Check the patient’s ID
wristband against documentation
e.g., case notes or request form for:
First name
Surname
Date of birth
Hospital number
MACDONALD
MORAG
ITU
ANAEMIA
11/07/1956
NOT KNOWN
100198E
ANY HOSPITAL
Step 2: The details on the patient’s wristband including the hospital number must then be checked against documentation e.g., patient case notes, blood request form to ensure that they are accurate.

22. Sampling Procedure Only bleed one patient at a time
Do NOT use pre-labelled tube
Hand write the sample tube beside the patient
Send the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergency
ONLY after all of the pre-sampling safety checks have been carried out should you start the procedure of taking the venous blood sample.
The key steps of the venous blood sampling task are as follows:
Prepare the skin and use a tourniquet to make the vessels patent
ensure that you do everything to minimise discomfort for the patient
Take precautions when you are carrying out blood sampling alongside other sampling procedures
- when the sample has been taken remove the tourniquet and then remove the needle
Apply a dressing to the site where the sample has been taken from.
The current BCSH guideline (BCSH, 1999) recommends that you do not use addressograph labels for sample labelling as this practice has been identified as a major cause of patient identification errors that can lead to fatal transfusion reactions.
Never pre-label the compatibility tube (i.e., do not write the details on the sample label in advance of drawing the blood). The sample tube must be labelled with the details taken from the patient’s wristband or as per local policy for identification of outpatients who have no wristband.
Complete the request form or the order com/ electronic system, making sure you include all the relevant information e.g., previous transfusion history or any special requirements. You should clearly state when the blood is required. The person filling in the form is responsible for identifying if the patient has special transfusion requirements.
Samples should be sent to the laboratory the most appropriate way for the clinical situation, routine samples should be sent by the identified method for your hospital. For urgent samples, you should notify the HTL by telephone and send the sample and request from by most rapid method or the identified method for your hospital i.e., local major haemorrhage protocol.

23. Labelling the venous blood sample
Hand written label to include:-
Full name
Date of birth
Hospital number
Gender
Date
Signature of person who has taken the sample
At the bedside
By the person taking the sample
Labelling errors are a contributory factor in patient safety incidents in the blood transfusion process. It is essential that you complete the handwritten label ACCURATELY AND LEGIBLY with the following information:
The patient’s full name, DoB, hospital number, 1st line of the patient’s address -wales, gender, date and your signature.
To maintain patient safety it is important that the label is completed by the patient’s bedside and is filled out by the person who has taken the venous blood sample.

24. Storage Component Red blood cells Platelets Fresh Frozen Plasma
Cryoprecipitate
Red Blood cells: Have a shelf life of 35 days and must be stored at 4°C (+2°C) in an authorised blood fridge with an audible alarm system and functional temperature recorder - never in domestic/drug fridge.
Current recommendations advise that transfusion of each unit of red cells should be completed within 4 hours of removal from controlled 40C storage.
Unused red cells that have been out of refrigeration and have not been transfused for reason within four hours, must be returned to the blood bank with clear documentation confirming the length of time out of refrigeration.
Once out of the cold chain, the pack will slowly warm to ambient temperature, increasing the risk bacterial proliferation and red cell metabolism. Blood bank quality procedures must ensure that all red cell unit available for transfusion have remained under approved storage conditions.
Platelets: Are stored in HTL at oC on an agitation rack. Never store in the fridge, this causes the platelets to aggregate irreversibly. Platelets have a shelf life of 5 days. If unused they must be returned to HTL, as the unit can be reissued.
FFP/CRYO: Are stored in frozen state (-30oC) for up to 2 years. Thawed rapidly at 37oC. Once thawed coagulation factors start to deteriorate. once thawed cannot be refrozen, if unused, should be returned to HTL for appropriate destruction. Since June 2005 FFP, FFP and cryoprecipitate for neonatal use (paedipacks) and for children under 16 years have been derived from imported plasma. These components are methylene blue treated as a pathogen reduction measure. 

25. Collection Procedure
Step 1: Complete the Blood Collection Form (or follow your local collection procedure) with the following information:
First name
Surname
Date of birth
Hospital number
It is vital that you positively identify the patient and ensure they have patent IV access before the component is collected. Any delay may result in wastage of the blood component
Step 1: You must ensure that the details on the Blood Collection Form or local documentation match the information on the patient’s wristband before completing the Blood Collection Form or phoning the portering service to ask for a blood component to be collected.
For each subsequent blood component collected the process must be repeated, i.e., a new blood collection form completed or telephone request made.
Follow procedure for each blood component collected

26. Collection Procedure Step 2: Check the patient’s ID
details against compatibility/
traceability label attached to
the blood bag
Step 3: Document removal
of unit on blood fridge register
or electronic release system
Step 2: On collection of the component from the HTL or satellite fridge the patient’s identification details must be checked against the patient compatibility/ traceability label attached to the blood bag.
Step 3: The person collecting the component must document the removal of the unit with the date/time and their signature on blood fridge register or electronic release system.
A trained member of staff should check and sign that the correct blood component has been delivered to the clinical area.
If returning an unused component to the HTL or the blood fridge you must document the date/time of return in the appropriate register as this is a requirement under the Blood Safety and Quality Regulations.
Ensure prompt delivery of the blood component to the clinical area

27. Pre-administration Procedure
Step 1: Check the blood component has been prescribed
Step 2: Undertake baseline observations
Step 3: Undertake visual inspection
LEAKS
DISCOLOURATION
CLUMPING
Check that IV access has been established, any delay may result in wastage of the blood component.
Step 1: Check the blood component has been prescribed. Check the prescription form and/ or fluid balance chart to ensure that the component has been prescribed and if the patient has any special requirements e.g., irradiated blood, and if they require any concomitant drugs prescribed, e.g., a diuretic.
Step 2: Undertake baseline observations. Ensure that the patient’s temperature, pulse and blood pressure are recorded before the blood component is administered.
Step 3: Check the component before approaching the patient. Undertake a visual inspection of the blood component for signs of discolouration, leaking, clots etc and check the expiry date and time.
EXPIRY DATE
If there is ANY discrepancy - DO NOT transfuse

28. Pre-administration checks
Personal checks:
- clean your hands
- wear personal protective equipment
Equipment checks:
- Personal protective equipment is available and is clean and sterile
- A correctly completed prescription chart
- Observation chart
- Giving set
- Disposable bags
- Trolley
The first type of checks are personal checks and include ensuring that you have washed your hands and are wearing the correct personal protective equipment. Ask the training delegates what they think are the key items of personal protective equipment and then summarise all of them.
State that the second type of check are equipment checks. These include:
Checking that personal protective equipment is available and is clean and sterile
ensuring that the prescription chart has been filled out correctly
Making sure that there is an observation chart and/or prescription chart available
Making sure that you have a giving set, disposable bags and a trolley available.

29. Administration Process
Equipment
Venous access devices
Blood administration sets
Infusion fluids
Infusion devices
Venous access devices: Blood components can be safely transfused through small gauge peripheral cannulae (e.g., 19/24 Gauge) or central lines, including umbilical catheters. Check your own unit’s policy before using these catheters as some neonatologists feel that the administration of blood through umbilical catheters (venous or arterial) may increase the risk of developing necrotising enterocolitis.
Infusion devices: The volume and rate of administration must be carefully controlled. An infusion device should be used for red cells, especially in the neonatal setting. Blood warmers are required when giving large volume rapid transfusion or for exchange transfusion in infants. Never warm blood in a sink of water or on radiators.
Blood administration sets: Syringe drivers are suitable for neonatal transfusion. Whatever kind of device is used, it is important to incorporate a suitable macroaggregate filter. This should be inserted between the bag and the syringe during syringe filling or between the syringe and the IV access device.
Infusion fluids: It is unnecessary to prime the administration set with saline unless checking patency of line. Do not prime with Dextrose or Ringer Lactate. Do not administer platelets through an administration set that has previously been used for red cells or other components as this may cause aggregation. Do not administer medication through a lumen used for transfusion of blood components. For ongoing transfusion change the giving set every 12 hours, or on completion of transfusion.  22

30. Administration Procedure
Step 1: Ask the patient to tell you their:
Full Name + Date of Birth
Check this information against the patient’s ID wristband
If you are interrupted - STOP, and start the checking procedure again
It is vital that you positively identify the patient
Step 1: This can best be achieved by asking the patient to tell you their NAME and DOB. This information must be checked against the patient’s wristband for accuracy.
In the unconscious patient (or in paediatric practice) it is imperative to verify the patient identification details with a second member of staff.
*In unidentified patients in the A/E department the unique identification number should be used at all times during the transfusion process *
Be extra vigilant when checking the identity of the unconscious / compromised patient

31. * IF THERE ARE ANY DISCREPANCIES - DO NOT PROCEED - CONTACT YOUR HTL *
Administration Procedure
Step 2: Check the patient’s
First name
Surname
Date of birth
Hospital number
on the compatibility/
traceability label against
the patient’s ID wristband
If you are interrupted - STOP, and start the checking procedure again
Step 2: Check the patient’s first name, surname, DOB and hospital number on the compatibility/traceability label attached to the blood bag against the patient’s ID wristband for accuracy.
* IF THERE ARE ANY DISCREPANCIES - DO NOT PROCEED - CONTACT YOUR HTL *

32. *IF THERE ARE ANY DISCREPANCIES - DO NOT PROCEED - CONTACT YOUR HT L*
Administration Procedure
Step 3: Check the compatibility/traceability label with the blood bag label
DONOR COMPONENT
NUMBER
BLOOD GROUP
RhD GROUP
If you are interrupted - STOP, and start the checking procedure again
Step 3: Check that the blood group and the donation number on the compatibility/traceability label attached to the blood bag are identical to the blood group and donation number on the blood component.
A different but suitable blood group which is compatible with the patient may have been issued. If you are unsure about the suitability of the component check with the HTL before transfusing.
*IF THERE ARE ANY DISCREPANCIES - DO NOT PROCEED - CONTACT YOUR HT L*
If there is ANY discrepancy - DO NOT transfuse

33. Documentation Procedure
EXAMPLE COMPATIBILITY/TRACEABILITY LABEL
EXAMPLE COMPATIBILITY REPORT FORM
COMPLETE DOCUMENTATION
Ensure that you sign the transfusion documentation to say you have checked the blood component against the patient’s wristband
G N
Red Cells
MACDONALD
MORAG
11/07/19566
FEMALE
25 HILL STREET
TOWN CENTRE
100198E
20/12/2006
Red Cells
O Rh POS
G N
Ensure donor component number is recorded on
the transfusion documentation
Complete documentation for every blood component transfused
The UK Blood Safety & Quality Regulations (2005) introduces a legal requirement to ensure unmistakable traceability of every blood component from donor to patient or final fate if not transfused. The related evidence is to be retained and accessible for 30 years. You should refer to your local traceability policy.
The donor unit number, the date and time of transfusion and the signature of person(s) undertaking the checking procedure must be recorded on the traceability and hospital transfusion documentation (compatibility form/ prescription sheet or transfusion record) for each component transfused.
The completed form must be filed in the patient case notes and kept as a permanent record of transfusion.
MACDONALD
MORAG
100198E
G N
Red Cells

34. Monitoring Procedure *Early Check* Communicate with patient
Record vital signs
*Early Check*
Each unit must be infused within four hours
Complete documentation
Patients should be transfused in an area where they can be readily observed and they should have a ‘call button’ to obtain assistance
You should advise your patient of the possible adverse effects of transfusion and tell them to inform someone if they experience any signs of a reaction.
The early check is the most important observation - the majority of major adverse reactions occur within first 15 minutes, thereafter observation should be conducted according to agreed local policy but you must continue to observe your patient throughout the transfusion.
Transfusion of each unit of red cells must be completed no more than 4 hours after it has been removed from controlled 40C storage. Current recommended infusion rates are:
Red blood cells hours
Fresh Frozen Plasma minutes
Cryoprecipitate 30 minutes
Platelets 30 minutes

35. Immediate Action to Take for Txn Rxn:
1. STOP THE TRANSFUSION
2. Keep IV open with Normal Saline
3. Check all blood component(s) labels, forms, Pt. ID for errors
4. Notify Pt.’s physician as appropriate
5. Treat rxn
6. Notify Blood Bank; submit work-up specimens; submit report forms

36. Investigations of transfusion reaction are necessary for :
Diagnosis
Selection of appropriate therapy
Transfusion management
Prevention of future transfusion reaction.
Investigations should include correlations of clinical data with
laboratory result .
Important clinical data :
Medical history of pregnancies, transplant, and previous transfusion.
Current medication
Clinical signs and symptoms of the reaction.

37. 5. Question related to the transfusion:
Amount of blood transfused to cause the reaction.
How fast , how long ?
The use of blood warmer.
Any filter used ? Other solutions.
Any drugs given at the time of transfusion

38. 2. As recquired procedures
ABO grouping and RH typing, pre and post transfusion
Major compatibility testing , pre and post transfusion
Antibody screening test , pre and post transfusion
Alloantibody identification
Antigen typings
Free hemoglobin in first voidedurine post transfusion
Unconjugated bilirubin 5 – 7 hours post transfusion.

39. 3. Extended procedures
Gram stain and bacterial culture of unit
Quantitative serum Hemoglobin.
Serum Haptoglobin , pre and post transfusion
Peripheral blood film.
Coagulation and renal output study
Urine hemosiderin

40. Incompatible Transfusion
Haptoglobin
Plasma HEMOGLOBIN
Urine Hemoglobin
Incompatible Transfusion
Serum bilirubin 6 12 18 24 30
Hours

41. Delayed Hemolytic Trn Rxn
Management
Send specimen(s) to Blood Bank for antibody identification work-up
Provide good Pt history

42. Delayed Hemolytic Trn Rxn
Prevention
Transfuse RBC’s that are phenotype negative for known clinically significant RBC antibodies in Pt
Delayed Hemolytic Trn Rxn’s can not be predicted
Good Pt records and Blood Bank records are essential
Clinical treatment usually not necessary

43. DHTR In the futureDHTR may be prevented; Artificial blood substitutes
More sensitive antibody screening method

44. In all cases in which transfusion is thought to be the cause of death,the FDA must be notified by phone within 24 h after discovery and this must followed up with a written report within 7 days(21 CFR )