SAFE BLOOD TRANSFUSION PRACTICES AND POLICY OF HOSPITAL CHANGKAT MELINTANG

DR LEE OI WAHPENGARAH

HCM

INTRODUCTION

• Blood transfusion is a safe process that saves lives and improves the quality of life in a large range of clinical conditions.

• But there are a number of risks associated with transfusion as with any other clinical intervention.

• More recently in 2003, SHOT recommended that health care staff should receive transfusion procedures training and formally assessed competency that is recorded if they contribute to the transfusion process (SHOT, 2003).

• REASON ???

Summary of UK Transfusion Practice Audit Results(Gray, Buchanan, McClelland, 2003;

RCP/NBS, 2003)

✦ 18% of patients had no identification check when the pre-transfusion sample was taken. ✦ 11% of blood components collected had no patient minimum data set check. ✦ 10% of patients were not wearing a wristband during their transfusion.

✦ 47% of patients had no vital signs monitored within the first 30 minutes of the transfusion

Typical SHOT IBCT errors (SHOT, 2004)

✦ The blood sample was drawn from the wrong patient. ✦ Patient details were recorded incorrectly on the blood sample label or the blood request form. ✦ The incorrect unit was collected from the blood refrigerator. ✦ The formal identity check at the patient’s bedside was omitted or performed incorrectly at the time of the administration of the blood component.

THE TRANSFUSION PROCESS• Every hospital must have policies and

procedures in place for every step in the blood transfusion process which includes :

Consent(informing the patient)SamplingCollection of blood bagPre-administrationAdministrationPatient monitoringTechnical aspect of blood transfusion

INFORMING THE PATIENT

“Every patient has a fundamental legal and ethical right to determine what happens to his or her own body.”

• When you care for a patient who is about to undergo a blood transfusion, you should:

✦ inform the patient about the intended transfusion therapy and give them the opportunity to discuss it and raise any concerns that they may have ✦ check that the decision to transfuse is recorded in the patient case notes before administering the blood component. ✦ check that a written consent is obtained form patient for each pint of blood transfused.

SAMPLING

• “Every patient who may require a transfusion during an inpatient or day patient episode will wear an identity band on which is recorded legibly the patient’s correct minimum identification data.”

• Patient minimum identification data set

✦ Name(s)

✦ Identification No/Passport No

When you take a blood sample, you should:

✦ ask the patient to state their first name, surname, and identification No to check that you have the right patient before you draw the sample.

✦ask another member of staff, relative or carer to verify the patient identification details if the patient is unable to do this, for example, because they are unconscious or a child.

✦ check the details against the patient’s identity wristband

✦ collect the required amount of blood into the appropriate sample tube.

✦ after you have drawn the blood sample and before you leave the patient, label the compatibility sample tube clearly and accurately with the patient details that you have taken from the identity wristband

✦ check that the patient details on the sample tube and request form correspond

✦ send the blood sample tube and request form to the hospital transfusion laboratory (HTL) with the appropriate request date and time.

COLLECTION• You should ensure that every blood component collected is checked against

the patient’s minimum identification data set.

• ✦ check that the details on the blood collection form, or local documentation,match the information on the patient’s wristband before passing the request to the person collecting the blood component

✦ check the patient’s identification details on the blood collection form, or local documentation, against the patient compatibility label on the blood component that you have just collected

✦ document the removal of the unit of blood by putting the date, time and signature of the person removing it onto the blood fridge register or electronic release system

✦ inform the person who requested the blood component that it has arrived as soon as it is delivered.

PRE-ADMINISTRATION You should check that the:

✦ patient understands the process and why the transfusion is being given, and explain the procedure fully

✦ blood component has been prescribed appropriately

✦ baseline observations of temperature, pulse and blood pressure are undertaken before starting the transfusion of each unit of blood ✦ expiry date of the blood component is correct, and undertake a visual inspection for any signs of discoloration, clumping or leaks.

You also need to check if the patient has any special requirements, such as a diuretic.

ADMINISTRATION

• You should ensure that every individual who needs a blood transfusion as an inpatient or day patient has a final identity check:

✦ positively identify the patient (see Box 2) using an open question “can you tell me your full name?

✦ ask another member of staff, relative or carer to verify the patient identification details if the patient is unable to do this if, for example, they are unconscious or a child.

✦ check these details against the patient’s wristband for accuracy

ADMINISTRATION

✦ check that the blood group and the donation number on

the compatibility label are identical to the blood group

and donation number on the blood component.

✦ If there are any discrepancies at this point, it is important that you do not proceed until they have been resolved.

✦ If you are interrupted in the checking procedure, you must start again.

✦ You must wash your hands, and follow your local infection control policy when you administer blood components.

PATIENT MONITORING• You should ensure that every patient who receives a

transfusion is monitored throughout the process.• Good record keeping is the mark of a skilled and safe

practitioner.• YOU SHOULD :

✦ ensure that the patient is in a setting where they can be closely observed

✦ advise and encourage your patient to notify you

immediately if they begin to feel anxious, or if they become aware of any adverse reactions such as shivering, flushing,pain or shortness of breath

PATIENT MONITORING ✦ monitor the patient’s temperature and pulse 15 min

after you begin the transfusion of each unit, and

record them on the transfusion observation chart.

✦ adjust the flow-rate so that you achieve the correct

infusion rate over the prescribed time period.

✦ continue routine observations throughout the transfusion for an unconscious patient: temperature, pulse, blood pressure, and urinary output.

✦ document the start and finish times of each unit

✦ record the volume of blood transfused on the fluid balance chart, or 24-hour chart

✦ document the donation number, component type, and date transfused of each blood component transfused in the patient’s case notes.

If you suspect a transfusion reaction:

✦ stop the transfusion and immediately inform the doctor

✦ if the reaction appears life-threatening, call the resuscitation team

✦ record the adverse event in the patient case notes

✦ report the adverse event in accordance with the hospital policy.

TECHNICAL ASPECT OF BLOOD ADMINISTRATION

✦ The size of the cannula depends on the size of the vein and the speed at which the blood is to be transfused.

✦ Blood components must be transfused through a blood administration set with an integral mesh filter (170–200μm pore size).

✦ Blood warmers can be used for blood components provided that they are specifically designed for that purpose, and include a visible thermometer and audible alarm.Never improvise by warming blood components in hot water, in a microwave or on the radiator.

✦ Do not add pharmaceuticals to blood components.

✦ Transfusion of each unit of red cells must be completed no more than four hours after it has been removed from controlled 4C storage. Red cell units that have been out of refrigeration and have not been transfused within four hours must be returned to the blood bank.

✦ Change the administration set at least every 12 hours for a continuing transfusion and on completion of the transfusion.

✦ Discard the empty blood bags according to your hospital policy.

IntroductionModule 12: Transfusion Reactions and

Adverse Events

Many of the serious adverse events that occur as a result of blood transfusion are unpredictable. The most important are:

Acute haemolytic transfusion reactions

Infusion of a bacteriallycontaminated unit

Transfusion-related acute lung injury (TRALI)

Severe allergic reaction or anaphylaxis

Post-transfusion purpura (PTP)

Transfusion-associatedGraft-versus-host

disease

It is often difficult to distinguish which type of reaction is taking place as the signs and symptoms of these reactions are very similar. These are detailed on the next slide.

Expert medical help should be sought from a haematologist and/or microbiologist if a transfusion reaction is suspected. It is often necessary to treat all possible causes.

West Midlands

Module 12: Transfusion Reactions and Adverse Events

Signs & Symptoms to look out for if a patient is having a transfusion reaction:

Acute reactions are rare but any new signs or symptoms, which develop during a transfusion, may be caused by a transfusion reaction. It is therefore

important to consider a transfusion reaction if there is any deterioration in the patient’s condition especially during the first 15-20 minutes of transfusion of blood / blood product.

Please note: In the following ‘suggested treatments’ – when returning the unit of blood / blood component to the hospital blood bank, check if the giving set should also be sent still attached

to the unit

Pyrexia

Tachycardia

Hyper / hypotension

Change in blood pressure

Haemoglobinuria

Vomiting / diarrhoea

Urticaria

Rigors

Collapse

Chest / back pain

Abdominal pain

Bone / muscle pain

Headache

Restlessness / agitation

Flushing

Nausea

Breathlessness / coughing

Generally feeling unwell

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Actions to take if a serious acute reaction is suspected

Module 12: Transfusion Reactions and Adverse Events

Stop the transfusion immediately and keep the IV line open with a slow infusion of saline (via a new giving set);

Call a doctor to see the patient urgently. It may be necessary to call the crash team depending on the severity of the reaction; resuscitation may be required.

Re-check the patient’s identity, ensure this corresponds with the unit of blood / blood Component and re-check all documentation;

Inform the blood bank. Blood and urine samples will be required to investigate the reaction (blood bank / medical staff will clarify what is required);

Check and record the patient’s temperature, pulse and blood pressure;

Check respiratory rate and respiratory signs – dyspnoea, tachypnoea, wheeze, cyanosis;

Check oxygen saturation and blood gases;

Provide further management depending on the patient’s clinical features. This may involve transfer to intensive care unit and mechanical ventilatory support.

It is important to document all observations, symptoms, signs, treatments and tests performed relating to the event.

Transfusion reactions can be fatal

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Symptoms/Signs of Acute Transfusion ReactionFever, chills, tachycardia, hyper or hypotension, collapse, rigors, flushing, urticaria, bone, muscle, chest and/or abdominal pain, shortness of breath, nausea, generally

feeling unwell, respiratory distress

Stop the transfusion and call a doctorMeasure temperature, pulse, BP, respiratory rate, O2 saturation

Check the identity of recipient, the details on the unit and compatibility form

Reaction involves mild fever or urticarial rash

only?

UrticariaMildfever

Mild Allergic reactionGive Chlorpheniramine 10mg slowly i.v. and restart the transfusion at a

slower rate and observe more frequently.

Febrile non-haemolytic transfusion reaction

If temp rise less than 1.5oC, the observations are stable and the

patient is otherwise well give Paracetamol.Restart infusion at slower rate and observe more

frequently

No

Suspected ABO incompatibility?

Recheck pack and patient ID

Yes

ABO IncompatibilityTake down unit and giving set.

Return intact to blood bank. Commence I.V. saline infusion.

Monitor urine output/catheterise. Maintain urine output at >100 mls/hr. Give frusemide if urine

output falls/absent. Treat any DIC with appropraite blood

components. Inform Hospital Transfusion Department

immediately.

No

Severe Allergic Reaction?

Yes

Severe allergic reactionBronchospasm, angioedema, abdominal pain, hypotension.

Discontinue transfusion.Return intact to blood bank along with

all other used/unused units. Give Chlopheniramine 10mg slowly i.v.

Commence O2, give salbutamol nebuliser. If severe hypotension, give adrenaline 0.5 ml of 1 in 1000 (i.e. 0.5 mg) i.m. Clotted sample to transfusion

laboratory. Saline wash future components.No

Continued on next slide

West MidlandsModule 12: Transfusion Reactions and

Adverse EventsManagement of severe acute reaction

Continued from previous slide

Other Haemolytic reaction /bacterial

contamination?

Yes

Haemolytic reaction/bacterial infection

of unitTake down unit and giving set.

Return intact to blood bank with all other used/unused

units. Take blood cultures, repeat blood group / crossmatch /

FBC, co ag screen, Biochemistry, urinanalysis.

Monitor urine output.Commence broad spectrum

antibiotics if suspected bacterial infection.

Commence oxygen and fluid support

Seek Haematological advice

No

Acute dyspnoea/hypotension

Monitor blood gasesPerform CXR, measure

CVP/Pulmonary capillary pressure

Raised CVP

Normal CVP

Fluid OverloadSTOP INFUSION

Give oxygen and Frusemide 40-80 mg i.v.

TRALIDyspnoea, chest x ray, “whiteout”. Discontinue transfusion. Give 100%

Oxygen. Treat as ARDS – Ventilate if hypoxia indicates

West MidlandsModule 12: Transfusion Reactions and

Adverse Events

From: ‘Handbook of Transfusion

Medicine 3rd Edition’.

© Crown Copyright material is reproduced with the permission of the Controller of HMSO and Queen’s printer for Scotland.

Key PointsModule 12: Transfusion Reactions and Adverse Events

Remember: Transfusion reactions can be fatal

• Many of the serious adverse events that occur as a result of blood transfusion are unpredictable.

• It is often difficult to distinguish which type of reaction is taking place as the signs and symptoms of these reactions are very similar.

• It is often necessary to treat all possible causes.

• If an acute transfusion reaction is suspected, this should be classed as a medical emergency and prompt action taken.

• If a transfusion reaction is suspected, always check that the correct patient is receiving the correct unit of blood / blood component.

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INVESTIGATION OF REACTION• Immediate sample : ✦ Venous sample 8-10ml (plain tube) ~ antibody/Gp/ ✦ 2-5 ml (EDTA) ~ FBP ✦ Blood for RP, LFT, DIVC screen ✦ Urine for inspection and hemoglobinuria ✦ Remaining blood & blood bag send to lab• 24hrs sample : same as above• Complete The “Report of Reaction to Blood or Plasma

Transfusion” form• Once the investigation of the transfusion adverse event

is complete, fill up the transfusion adverse event form in duplicate and send to the blood bank. Send also a copy of this form to the National Blood Centre.