5Allergic Rxn Management Premedicate Pt with antihistamines (e.g. Benadryl)If signs/symptoms mild &/or transient, restart transfusion after treatmentDo NOT restart transfusion if pulmonary symptoms/signs, fever present
6Allergic RxnPreventionProphylactically treat with antihistamines
7TRALI Management Steroids Aggressive ventilatory support Hemodynamic support
8TRALIPreventionTypically ,TRALI is adonor specific phenomen so donor deferred from donating plasma products.Transfuse washed RBC’s from which plasma is removedPlatelet units can also be washed, but platelet function is significantly reduced
9Circulatory Overload Management Slow rate of infusion Place Pt in upright position, if possible, with feet in dependent positionDiureticsOxygenMorphine (if necessary)
10Circulatory Overload Prevention Vigilant assesment of patients input and outputSlow rate of infusionPretransfusion and/or intratransfusion diuretic adminstration
11Septic Rxn Management Obtain blood cultures from Pt Return blood component bag(s) to blood bank for further laboratory work-upTreat septicemia with antibioticsTreat shock with fluids & vasopressors
12Septic RxnPreventionCollect, 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
13Acute Hemolytic Management Treat hypotension, renal failure, DIC, etc. Submit blood samples for blood bank/laboratory testsAvoid, if possible, further transfusions till work-up complete and/or Pt recovered from rxn
14MANAGEMENT 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 specimens6-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
15Continue….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.
16prevention The best way to prevent AHTR is to avoid transfusion Defining clear-cut and defendable indication for transfusionCareful determination of the Hb or HCT level for ordering TRXpatient-donor identificationAutologousblood safer than homologous
17Serious 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!*
18Serious 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 groupInappropriate specification: Failure to provide irradiated blood components for patients treated with purine analogues or who have undergone stem cell transplantationPre–transfusion testing errors: Incorrect blood groups, missed alloantibodies and missed incompatibilitiesInappropriate transfusion: Full blood sample unsuitable, sample taken from drip arm, full blood results wrongly transcribed, transfusion before haematology results availableHandling 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
19Requesting Procedure Check the patient’s case note Transfusion history Special requirementse.g., irradiated, CMV negativeComplete request form or order comThe 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.
20Full Name + Date of Birth Sampling ProcedureStep 1: Ask the patient to tell you their:Full Name + Date of BirthCheck this information against the patient’s ID wristbandBefore 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
21Sampling Procedure Step 2: Check the patient’s ID EXAMPLE REQUEST FORMStep 2: Check the patient’s IDwristband against documentatione.g., case notes or request form for:First nameSurnameDate of birthHospital numberMACDONALDMORAGITUANAEMIA11/07/1956NOT KNOWN100198EANY HOSPITALStep 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.
22Sampling Procedure Only bleed one patient at a time Do NOT use pre-labelled tubeHand write the sample tube beside the patientSend the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergencyONLY 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 patentensure that you do everything to minimise discomfort for the patientTake 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 needleApply 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.
23Labelling the venous blood sample Hand written label to include:-Full nameDate of birthHospital numberGenderDateSignature of person who has taken the sampleAt the bedsideBy the person taking the sampleLabelling 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.
24Storage Component Red blood cells Platelets Fresh Frozen Plasma CryoprecipitateRed 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.
25Collection ProcedureStep 1: Complete the Blood Collection Form (or follow your local collection procedure) with the following information:First nameSurnameDate of birthHospital numberIt 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 componentStep 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
26Collection Procedure Step 2: Check the patient’s ID details against compatibility/traceability label attached tothe blood bagStep 3: Document removalof unit on blood fridge registeror electronic release systemStep 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
27Pre-administration Procedure Step 1: Check the blood component has been prescribedStep 2: Undertake baseline observationsStep 3: Undertake visual inspectionLEAKSDISCOLOURATIONCLUMPINGCheck 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 DATEIf there is ANY discrepancy - DO NOT transfuse
28Pre-administration checks Personal checks:- clean your hands- wear personal protective equipmentEquipment checks:- Personal protective equipment is available and is clean and sterile- A correctly completed prescription chart- Observation chart- Giving set- Disposable bags- TrolleyThe 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 sterileensuring that the prescription chart has been filled out correctlyMaking sure that there is an observation chart and/or prescription chart availableMaking sure that you have a giving set, disposable bags and a trolley available.
29Administration Process EquipmentVenous access devicesBlood administration setsInfusion fluidsInfusion devicesVenous 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
30Administration Procedure Step 1: Ask the patient to tell you their:Full Name + Date of BirthCheck this information against the patient’s ID wristbandIf you are interrupted - STOP, and start the checking procedure againIt is vital that you positively identify the patientStep 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 ProcedureStep 2: Check the patient’sFirst nameSurnameDate of birthHospital numberon the compatibility/traceability label againstthe patient’s ID wristbandIf you are interrupted - STOP, and start the checking procedure againStep 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 ProcedureStep 3: Check the compatibility/traceability label with the blood bag labelDONOR COMPONENTNUMBERBLOOD GROUPRhD GROUPIf you are interrupted - STOP, and start the checking procedure againStep 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
33Documentation Procedure EXAMPLE COMPATIBILITY/TRACEABILITY LABELEXAMPLE COMPATIBILITY REPORT FORMCOMPLETE DOCUMENTATIONEnsure that you sign the transfusion documentation to say you have checked the blood component against the patient’s wristbandG NRed CellsMACDONALDMORAG11/07/19566FEMALE25 HILL STREETTOWN CENTRE100198E20/12/2006Red CellsO Rh POSG NEnsure donor component number is recorded onthe transfusion documentationComplete documentation for every blood component transfusedThe 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.MACDONALDMORAG100198EG NRed Cells
34Monitoring Procedure *Early Check* Communicate with patient Record vital signs*Early Check*Each unit must be infused within four hoursComplete documentationPatients should be transfused in an area where they can be readily observed and they should have a ‘call button’ to obtain assistanceYou 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 hoursFresh Frozen Plasma minutesCryoprecipitate 30 minutesPlatelets 30 minutes
35Immediate Action to Take for Txn Rxn: 1. STOP THE TRANSFUSION2. Keep IV open with Normal Saline3. Check all blood component(s) labels, forms, Pt. ID for errors4. Notify Pt.’s physician as appropriate5. Treat rxn6. Notify Blood Bank; submit work-up specimens; submit report forms
36Investigations of transfusion reaction are necessary for : DiagnosisSelection of appropriate therapyTransfusion managementPrevention of future transfusion reaction.Investigations should include correlations of clinical data withlaboratory result .Important clinical data :Medical history of pregnancies, transplant, and previous transfusion.Current medicationClinical signs and symptoms of the reaction.
375. 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
382. As recquired procedures ABO grouping and RH typing, pre and post transfusionMajor compatibility testing , pre and post transfusionAntibody screening test , pre and post transfusionAlloantibody identificationAntigen typingsFree hemoglobin in first voidedurine post transfusionUnconjugated bilirubin 5 – 7 hours post transfusion.
393. Extended proceduresGram stain and bacterial culture of unitQuantitative serum Hemoglobin.Serum Haptoglobin , pre and post transfusionPeripheral blood film.Coagulation and renal output studyUrine hemosiderin
41Delayed Hemolytic Trn Rxn ManagementSend specimen(s) to Blood Bank for antibody identification work-upProvide good Pt history
42Delayed Hemolytic Trn Rxn PreventionTransfuse RBC’s that are phenotype negative for known clinically significant RBC antibodies in PtDelayed Hemolytic Trn Rxn’s can not be predictedGood Pt records and Blood Bank records are essentialClinical treatment usually not necessary
43DHTR In the futureDHTR may be prevented; Artificial blood substitutes More sensitive antibody screening method
44In 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 )