Transfusion for Medical StudentsNov 2013

Requesting blood for transfusion

• What is a group and screen test?The patient’s blood group is checked and an antibody screen is performed on the patient’s plasma. The sample can be kept in the lab for up to 6 days and then a crossmatch can be subsequently requested• What is a crossmatch test?The patient’s plasma is mixed with the donor’s red cells to make sure there is compatibility. When ordering state amount, time required, urgent / routine (look at surgical blood order schedule for elective surgery)

Case 1: 27-year-old patient has a massive post-partum haemorrhage with severe hypotension.

• Emergency Gp O RhD negative blood does not need to be crossmatched T

• Fully crossmatched blood would take 45 mins to be made available F

• If O RhD blood is given there is no need to take a crossmatch sample F

• Group specific blood can be made available in 15-30 mins

ASSESS URGENCYChoose the right products

COMMUNICATEAllocate a lead to liaise with lab &

porters

AVOID ERRORSCareful bedside labelling

XM, FBC, coag screen – swiftly to lab

REQUESTING BLOODGroup O

Important antibodies may cause reactionValuable resource

Extreme emergency only

Group specificABO & RhD compatible

Important antibodies may cause reaction

~15mins from sample arriving

CrossmatchedFully screened for antibodies

~45-60 mins from sample arriving

Safest product if time allows

Preempt need for FFP (30mins to thaw; 12-15mL/kg = 4 units for average adult)Preempt need for platelets

Pre transfusion testingOn receipt of the pre-transfusion sample the following steps are undertaken:•Check the historical records•Group: Identify ABO and RhD group•Screen: Check plasma for antibodies•Crossmatch: Select component

The patient’s serum or plasma can be saved for up to 6 days in case later cross-match is required

Transfusion Management of Massive HaemorrhagePatient bleeding / collapses

Ongoing severe bleeding eg: 150 mls/min and Clinical shockAdminister Tranexamic Acid

(1g bolus followed by 1g infusion over 8 hours)

Patient bleeding / collapsesOngoing severe bleeding eg: 150 mls/min and Clinical shock

Administer Tranexamic Acid(1g bolus followed by 1g infusion over 8 hours)

Call for help‘Massive Haemorrhage, Location, Specialty’Alert emergency response team (including

blood transfusion laboratory, portering/ transport staff)

Consultant involvement essential

Call for help‘Massive Haemorrhage, Location, Specialty’Alert emergency response team (including

blood transfusion laboratory, portering/ transport staff)

Consultant involvement essential

Take bloods and send to lab:XM, FBC, PT, APTT, fibrinogen, U+E, Ca2+

NPT: ABG, TEG / ROTEM if availableand

Order Massive Haemorrhage Pack 1Red cells* 4 unitsFFP 4 units

Platelets 1 dose (ATD)(*Emergency O blood, group specific blood,

XM blood depending on availability)

Take bloods and send to lab:XM, FBC, PT, APTT, fibrinogen, U+E, Ca2+

NPT: ABG, TEG / ROTEM if availableand

Order Massive Haemorrhage Pack 1Red cells* 4 unitsFFP 4 units

Platelets 1 dose (ATD)(*Emergency O blood, group specific blood,

XM blood depending on availability)

ReassessSuspected continuing haemorrhage

requiring further transfusionTake bloods and send to lab:FBC, PT, APTT, fibrinogen, U+E, Ca2+

NPT: ABG, TEG / ROTEM if available

ReassessSuspected continuing haemorrhage

requiring further transfusionTake bloods and send to lab:FBC, PT, APTT, fibrinogen, U+E, Ca2+

NPT: ABG, TEG / ROTEM if available

Give MHP 2Give MHP 2

Insert local arrangements:Activation Tel Number(s)

•Emergency O red cells- location of supply:

* Time to receive at this clinical area:•Group specific red cells

• XM red cells

Insert local arrangements:Activation Tel Number(s)

•Emergency O red cells- location of supply:

* Time to receive at this clinical area:•Group specific red cells

• XM red cells

STOP THE BLEEDING

RESUSCITATEAirway

BreathingCirculation

Haemorrhage ControlDirect pressure / tourniquet if appropriateStabilise fracturesSurgical intervention – consider damage control surgeryInterventional radiologyEndoscopic techniques

Haemorrhage ControlDirect pressure / tourniquet if appropriateStabilise fracturesSurgical intervention – consider damage control surgeryInterventional radiologyEndoscopic techniques

Haemostatic Drugs

Vit K and Prothrombin complex concentrate for warfarinisedpatients andOther haemostatic agents: discuss with Consultant Haematologist

Haemostatic Drugs

Vit K and Prothrombin complex concentrate for warfarinisedpatients andOther haemostatic agents: discuss with Consultant Haematologist

Prevent HypothermiaUse fluid warming deviceUsed forced air warming blanket

Prevent HypothermiaUse fluid warming deviceUsed forced air warming blanket

Cell salvage if available and appropriateConsider ratios of other components: 1 unit of red cells = c.250 mlssalvaged blood

Cell salvage if available and appropriateConsider ratios of other components: 1 unit of red cells = c.250 mlssalvaged blood

Consider 10 mls Calcium chloride 10% over 10 minsConsider 10 mls Calcium chloride 10% over 10 mins

2 packs cryoprecipitate if fibrinogen < 1.5g/l or as guided by TEG / ROTEM

2 packs cryoprecipitate if fibrinogen < 1.5g/l or as guided by TEG / ROTEM

Aims for therapyAim for:Hb 8-10g/dlPlatelets >75 x 109/lPT ratio < 1.5APTT ratio <1.5Fibrinogen >1.5g/lCa2+ >1 mmol/lTemp > 36oCpH > 7.35 (on ABG) Monitor for hyperkalaemia

Aims for therapyAim for:Hb 8-10g/dlPlatelets >75 x 109/lPT ratio < 1.5APTT ratio <1.5Fibrinogen >1.5g/lCa2+ >1 mmol/lTemp > 36oCpH > 7.35 (on ABG) Monitor for hyperkalaemia

STAND DOWNInform lab

Return unused components

Complete documentationIncluding audit

proforma

Transfusion lab

Consultant Haematologist

Transfusion lab

Consultant Haematologist

Thromboprophylaxis should be considered when patient stable

Give MHP 1Give MHP 1

ABG – Arterial Blood Gas APTT – Activated partial thromboplastin time ATD- Adult Therapeutic DoseFFP- Fresh Frozen plasma MHP – Massive Haemorrhage Pack NPT – Near Patient TestingPT- Prothrombin Time TEG/ROTEM- Thromboelastography XM - Crossmatch

Order Massive Haemorrhage Pack 2Red cells 4 unitsFFP 4 units

Platelets 1 dose (ATD)and subsequently

request Cryoprecipitate 2 packsif fibrinogen <1.5g/l or according to TEG /

ROTEM

Order Massive Haemorrhage Pack 2Red cells 4 unitsFFP 4 units

Platelets 1 dose (ATD)and subsequently

request Cryoprecipitate 2 packsif fibrinogen <1.5g/l or according to TEG /

ROTEM

Once MHP 2 administered, repeat bloods:FBC, PT, APTT, fibrinogen, U+E,

NPT: ABG, TEG / ROTEM if availableTo inform further blood component

requesting

Once MHP 2 administered, repeat bloods:FBC, PT, APTT, fibrinogen, U+E,

NPT: ABG, TEG / ROTEM if availableTo inform further blood component

requesting

Activate Massive Haemorrhage Pathway

Continuous cardiac monitoringContinuous cardiac monitoring

v1 2011

Recognise blood loss

Resuscitate, call for help

Stop the bleeding – TXA, PCC

Team approach

Emergency runner

Communicate with lab early and clearly

Know where the Emergency O Neg is in your Trust

Massive haemorrhage packs 1 and 2

Monitor coag tests and move to goal directed therapy

Stand down

Case 2

67-year-old male, Mr Arvind Patel, (Group O) is admitted for elective hip replacement surgery. His Hb is 100 g/L. Because of excessive bleeding on the operating table the Consultant Anaesthetist asks for 2 units of blood. The theatre nurse collects 2 units of red cells labelled for Mr Suhail Patel and starts transfusion. Mr Suhail Patel is Group B.

What are the potential clinical consequences for Mr Arvind Patel and how would they be

managed?

A. There would be no problems as it is safe to give Group B blood to a Group O donor so the transfusion could continue F

B. The transfusion must be stopped immediately TC. The partially transfused bag must be returned to

the lab with a blood sample from the patient TD. Oozing from venepuncture sites might be a sign

of a transfusion reaction T

Blood Groups Blood Group Antibodies

A Anti-B

B Anti-A

AB None

O Anti-A Anti-B

RhD positive or RhD negative

A

OAB

B

How could the error have been avoided?

A. The theatre nurse collecting the blood should make a note of the patient’s details so that she can identify the correct patient F

B. The bag of blood should be checked against the patient’s notes F

C. The bag of blood should be checked against the patient’s wrist band T

D. There is no need to do the bedside check when the patient is anaesthetised F

Could the transfusion have been avoided in the first place?

A. Yes because this type of surgery is suitable for cell salvage T

B. Yes because a Hb of 100g/L is a safe level for a 67 year old man F

C. No because the Hb alone is not the only trigger for transfusion T

D. Tranexamic acid would help to reduce blood loss in this situation T

BLOOD“1 unit RBC”

Usual time: 3hrs

4hr limit from removal from cold storage

to end of transfusionBlood warmer for rapid transfusions

COMMON INDICATIONS

Acute blood lossOnly with significant blood volume loss

Consider cell salvage

Anaemia Hb < 70 g/LLikely requires transfusionConsider correctible causes

Anaemia Hb 70 - 100 g/LConsider correctible causes

Transfuse if symptoms/needs eg IHD

Pre-operative assessmentCorrection of anaemia reduces need for

transfusionMBOS (Maximum Blood Ordering

Schedule)

Refer to Trust Blood Transfusion Policy

Case 3: 17-year-old female with heavy periods presents with Hb of 50 g/L and MCV 55 fl.

Would you give a blood transfusion?

A. Yes, I would give a blood transfusion – that Hb level is very low F

B. No, I wouldn’t give a blood transfusion because she will respond to an alternative therapy T

C. Oral iron will increase the Hb by 40g in 1 week F

Case 4: A full blood count states the platelet count to be ‘6 x 109/L’ with an associated peripheral blood film comment of ‘platelet clumping seen’. A prophylactic platelet transfusion (1ATD) is

indicated as the platelet count is <10 x 109/L. T/F

The answer is False

Fresh Frozen Plasma (FFP) is the optimal treatment available to treat life-threatening

bleeding in patients on warfarin T/F

The answer is False

Red Cells Whole Blood Platelets (also apheresis)

Plasma Fresh Frozen Plasma Cryoprecipitate

Fractionation

Factor concentrates Eg FVI I I , FI X, PCC

I mmunoglobulin Albumin (Non UK Plasma)

Blood Components

BLOOD COMPONENTS Fresh Frozen Plasma

“1 unit FFP”Usual time: 30 mins/unit

Needs 30 mins to thaw in labUsual dose 12-15 mL/kg (4-6 units for average

adult)Main indications: coagulopathy with

bleeding/surgery, massive haemorrhage, TTP. Not warfarin

reversal.

Cryoprecipitate“1 pool cryoprecipitate”Usual time: 30 mins/bag

Needs 30 mins to thaw in labAdults: 1 pool = 5 donor units

Usual adult dose: 2 pools (10 donor units)Main indication:

coagulopathy with fibrinogen < 1.5 g/L

Platelets“1 ATD platelets”

Usual time: 30 mins1hr limit

Usual dose: 1 adult treatment dose (ATD)Shelf-life only 7 days from donation

Used as prophylaxis or treatment of bleeding / pre procedure in patients with

thrombocytopeniaProthrombin Complex

Concentrate (PCC)Plasma-derived

Vit K dependent factors: II VII IX X

For emergency reversal of life-threatening warfarin over-

anticoagulation(do not use FFP)

Issued by transfusion lab – supply in A&E

See trust policy

PlateletsMassive haemorrhage

Keep platelet count above 75 x 109/lBone marrow failure

platelet count <10 × 109/l or <20 × 109/l if additional risk, e.g. sepsis

Prophylaxis for surgeryMinor procedures 50 x 109/l;More major surgery 80 x 109/l; CNS or eye surgery 100 x 109/l

Cardiopulmonary bypassPlatelets should be readily available use only if bleeding

Special Blood Requirements• All patients with Hodgkin’s Disease should receive irradiated

blood T• All patients born after 1996 should have virally inactivated,

non-UK sourced Plasma T• All Stem Cell Transplant / Bone marrow transplant recipients

require CMV negative blood F• Pregnant women have no special blood requirements, so

there is no need to inform the transfusion laboratory of their pregnancy or gestation on the request form F

SPECIAL REQUIREMENTS

CMV NEGATIVE

To keep at-risk patients CMV free(~50% of us are CMV negative)

Children < 1yrIntrauterine transfusions

Congenital immunodeficiencyand unless known to be CMV IgG

+ve:Pregnant women having elective

transfusion

IRRADIATEDTo prevent transfusion-associatedgraft versus host disease (rare)

in specific T-cell immunodeficiency cases

Intrauterine transfusionsCongenital immunodeficiency

Hodgkin LymphomaStem cell / marrow transplant

patientsAfter purine analogue chemo

(eg: fludarabine)

Fairly specific indications… Paeds, Haem, Onc, O&G… …but “it is the responsibility of the prescribing doctor”

Refer to Trust Blood Transfusion Policy

Risks of Transfusion• The risk of transmission of HIV with transfusion of red cells is

1 in 5 million donations in the UK (0.2 per million donations). T

• A patient becomes acutely short of breath following a transfusion of FFP. Chest X-ray shows bilateral pulmonary infiltrates and you give diuretics with some effect. The case should be reported as a clinical incident via the hospital reporting system, so it can be followed up appropriately. T

• All donors are now screened for vCJD F

Risks of Transfusion

• A patient complains of feeling unwell during their transfusion. Their observation chart shows their temperature, BP, pulse rate and respiratory rate to be stable. No specific action is required. F

• A patient develops mild urticaria following a platelet transfusion. You should administer IV chlorphenamine (piriton) and IV hydrocortisone. F

• Anaphylaxis is most likely to happen in the first 15 minutes of transfusion T

Serious Adverse Events from blood transfusion reported in UK 1996-2011

Risk of giving wrong blood is much greater than transfusion transmitted infection

TRANSFUSON REACTIONS

Suspectedsevere

reactionPyrexia, rigorsHypotension

Loin / back painIncreasing anxiety

Pain at the infusion siteRespiratory distress

Dark urineSevere tachycardia

Unexpected bleeding (DIC)

Mild reactionTemp rise < 1.5°C

UrticariaRash

Pruritis

STOP TRANSFUSIONReview obsParacetamolChlorpheniramine?Restart cautiously

STOP TRANSFUSIONRight patient?Right blood product?Whole set to labNew set with salineFull bloods as policyChecklist (see policy)Incident form

Refer to Trust Blood Transfusion

Policy

Trust Blood Transfusion Policy

OR

www.transfusionguidelines.org.uk

OR

Ask for help

Yes

Severe / life-threatening•Call for urgent medical help•Initiate resuscitation- ABC•Discontinue transfusion and maintain venous access•Monitor the patient : TPR, BP, urinary output, oxygen sats

Anaphylaxis follow anaphylaxis pathwayIf bacterial contamination policy likely start antibiotic treatmentInform hospital transfusion departmentReturn unit and administration set to transfusionPerform appropriate investigations

Not Life threatening or Severe

Resources

Trust Guidelines and Policies

The Transfusion Handbookwww.transfusionguidelines.org.uk

Your Hospital Transfusion Team