2IntroductionYou will need to be competent in all areas of blood transfusion prior to becoming a PRHO; This module will direct your learning but it is up to you to put the knowledge and skills into practice. The skills should be attempted in a skills centre before being practiced in the clinical setting.
3Aims and ObjectivesThis module is designed to direct your learning around the knowledge and skills associated with blood transfusionBy the end of this module students should beAware of the ‘when, where, why and who’ of blood transfusionAware of the steps necessary to order a blood transfusion and the common reasons why this process failsAble to write up a blood transfusionAble to set up a blood transfusionAware of the common complications of blood transfusion and their treatmentsCalculate the required drip rate for a unit of blood
4Challenging Knowledge - I For each of the following patients list:-(a) If you would transfuse them and(b) How many units you would give them, if any.(c) What other investigations would you order; What further management would you think about23 yo asymptomatic, healthy woman with menorrhagia - Hb 8.9 g/dl, MCV 73fl86 yo asymptomatic man with occasional angina – Hb 9.6 g/dl, MCV 104fl61 yo man with severe gram negative sepsis – Hb 7.0 g/dl, MCV 81fl54 yo woman post hemicolectomy Hb 8.3g/dl, MCV 84fl73 yo man presenting with acute upper GI bleed; BP 80/60, Pulse 120 thready – Hb 8.0 g/dl, MCV 101fl
5Menorrhagia leading to iron deficiency anemia 8.9 73 No transfusion PatientHb (g/dl)MCV (fl)TransfusionOther Treatment23yo femaleMenorrhagia leading to iron deficiency anemia8.973No transfusionFeSO4Investigate if severe86yo maleMacrocytic anaemia9.6104Investigate for macrocytosisDrugs, Alcohol,Hypothyroidism, Haemolysis61yo maleSevere G negative sepsis leading to normocytic anaemia7.081Transfuse 2 -3 units initiallyTreat severe sepsis – ceftazidine and gentamicin54yo femalePost-operative normocytic anaemia8.384Re-check Hb to ensure no further drop73yo maleMacrocyosis probably alcohol related with ? Varicael bleed7.9101Transfusion – Xmatch 6 units;ResuscitateUrgent OGD: May also have coagulpathy and thrombocytopaenia
6Challenging Knowledge II Before attempting the skills in this module - List the steps you would takeIn order to cross match a patient for a blood transfusionTo set up a blood transfusionList the common complications of a blood transfusion and their treatment.
7Blood and Blood Product Transfusion You should be familiar with each of these blood products. What are their indications and the complications associated with them?Whole BloodPacked CellsPlateletsFresh Frozen Plasma (FFP)Cryoprecipitate
8The Principle Aims of Blood Transfusion are to:- Improve oxygen carrying capacity of blood.Symptomatic improvement.Reduce hypovolaemia.1 UNIT of Blood should increase the Hb by approx.1g/dL.If no improvement or reduction in Hb – think about ongoing blood loss or destruction.You need treat the underlying cause.
9Blood Transfusion Indications - I The Sanguis Study, 1994No consensus on who, when, where and why to transfuse a patientA lot of variation in practice – dependent mainly on the individual clinician ordering the transfusion‘Strong suggestion that inappropriate use is widespread’
10Indications for Blood Transfusion Acute AnaemiaSymptomatic hypovolaemia and blood loss.Peri-operative – ‘replacing losses’Haemolysis (treat the underlying cause)Severe, critical illness.
11Blood Transfusion Indications - II Acute AnaemiaIncrease oxygen carrying capacity of blood- Young adults can tolerate 30 – 40% volume loss with adequate crystalloid replacement alone- Weiskopf et al (1988) – Euvolaemic anaemia in healthy volunteers (and patients) down to Hb ≥5g/dL (!) – No demonstrable inadequate tissue oxygenation- I.e. Only for symptomatic hypovolaemia
12‘Keep the Hb ≥ 10 g/ dL’ (2) Peri -operative Much quoted by Surgeons still - ‘Keep the Hb ≥ 10 g/ dLBUTCarson et al (1988); Stehling & Simon (1994)Patients tolerated Hb 8 – 10 g/dLNo patients died with Hb ≥ 8g /dL and ≤ 500ml blood lossNo data on morbidity ? Healing / recovery etc
13Severe illness – Expensive Scare (3) Severe and critical illnessOxygen delivery is dependent on:(a) Cardiac output (c.o.)(b) Oxygen content of bloodHowever there is very little change in C.O. until Hb ≤ 7 g/dL.Herbert et al, 1999 – recommended this was the level taken for transfusion in the critically ill unless other factors were present.
14Recommendations for Transfusion Bracey et al, 1999≤ 9 g/dL – CABG operation≤ 8 g/ dL – Symptomatic anaemia and blood loss≤ 7g/dL – Critically ill (Herbert et al)But: on-going and further blood loss must be taken into consideration as must the clinical situation and co-morbidity!
15Pale Mrs McPale – Hb ‘Unmeasurable’ Chronic AnaemiaTransfuse according to- Symptoms- Co-morbidities- Level of ActivityCorrect underlying cause and deficiencies‘Beware the ‘well patient’ with the macrocytic anaemia, Hb of 2g/dL – ‘Slowly down – Slowly up’; Remember their blood may be ‘see through’ but they are essentially euvolaemic. A large, rapid transfusion will cause fluid overload and pulmonary oedema.
16Conclusions Acute Anaemia Treat Patient according to situation - Co-morbidities- Symptoms- Cause of the Anaemia- Severity and likelihood of re-bleedRed Cell Transfusion SHOULD not be solely used as a ‘plasma expander’ – but primarily as a method to increase oxygen carrying capacity.
17Pre – Transfusion Considerations Does the patient need the transfusion?Does the patient want the transfusion?- Verbal consent- ? Soon to be written consentCross match vs Group and Save?How many units to Cross? (As opposed to many rivers to cross (ho ho))When to re-cross in active bleedingLocal haematology policies
18Does the patient need the transfusion? Yes:Symptomatic anaemiaSignificant blood lossAnaemia / severe illnessImproving Oxygen capacity of the bloodNo:Asymptomatic Hb ≥ 8 g/dL‘Well’ patient receiving alternative therapies – EPO or Iron‘Euvolaemic’ Anaemia secondary to B12 and folate deficiencies
19Does the patient want the transfusion? Consent- Recommended to obtain verbal consent from every patient; ?Soon to be written.Need to discuss:- Indication; Benefits- Risks - Infectious incidence HIV 1per 3x 106HBV 1per2 x 105- Non Infectious e.g. Transfusion reaction- Patient’s right to refuse transfusion e.g. Jehovah’s witnesses, has to be respected if decision made when competent.- Most hospitals now have Blood Transfusion nurse specialist to assist with these issues.
20Requesting Blood and Blood Products Bureaucratic errors are the commonest cause of blood transfusion problems – DON’T BE A STASTISTIC!Requests will not (and should not) be processed if any of the following stages are missed or are wrong.(a) Request Form details(b) Blood bottle details(c) No patient wrist band or missed details on the band (If phlebotomist is taking the blood).
21Write up the Blood Transfusion Cross match request using the form provided Mrs Kathy Lawrence is a 79yo woman with myelodysplasia. She has been re-admitted with a symptomatic anaemia, Hb 4.9 g/dl, MCV 87. Please write a request form for her cross match using the form provided.Hospital number ; DOB 13/09/24; Turner ward; Multiple transfusions over the last 6 months; Blood group A Rh +; No known antibodies; Four pregnancies
23Patient Details required – apply within Patient Details required on formFull namesDOBHospital NumberLocationBlood Group (if known)Previous transfusion and obstetric historyTransfusion detailsReason for request; Present Hb (if known)Location, Date and Time of expected transfusionDate of requestType of blood (Packed cells, whole blood, G&S only); Number of units.Doctor DetailsName, Bleep number and Signature of person requesting the bloodLABELS ARE NEVER ALLOWED ON THE FORMS OR THE BOTTLES
24Sample Collection – No magazines available Check patient details on wrist band vs form.Use Pink cross match bottle (In use nationally)Details required on Blood bottle- Full names of patient- DOB; Gender; Hospital number- Signature of person taking blood- Date and LocationTake blood bottle down to the blood bank if required urgently – you will also meet the cross match team (essential when you need a favour) and where the blood fridge is situated.PATIENT LABELS WILL NOT BE ACCEPTED!
25Setting up the Transfusion Units of blood are stored in the ‘blood bank’ fridge or theatre fridge.You will need all the patient’s details prior to going to collect any blood productsCheck details of blood report form against unit of blood.[Do not accept any wrong or missing details]You will need to sign for the unit in blood bank register; The responsibility is therefore yours!Start transfusion within 30 minutes of blood being removed from the fridge.This picture is for those that have never seen a fridge!
26The Ian Wright, Wright ,Wright Rule The Right Blood,The Right Patient,The Right Time!Why can’t you use this unit of blood unless you are a Vet?
27Cross Match or Group and Save (G&S) Guides (particularly for major surgical procedures) are available in most hospitals.Most haematology labs can cross match blood in 20 minutes.Cross match when(a) Significant, on-going or potential significant blood loss(b) Severe symptomatic anaemia or illness
28Prescribing Blood Transfusion Please write up the a four unit blood transfusion for Mrs Lawrence using the fluid chart supplied.The correct format is shown on the next slide.Why do we give frusemide?What is the slowest rate of transfusing a unit of blood?
29Ward: Turner Hospital No:213436 Consultant: Feather Name; Kathy LawrenceDOB: 13/09/24WeightDateCentral or peripheral lineType of Infusion FluidVolume of Infusion Fluid (ml)Drug to be addedTotal dose in bagInfusion RateDoctor’s signaturePBlood1 unit4 hoursFrusemideIV 40mgAfter second unitAfter fourth unitN. Saline100mlTo flush the line20 minutes
30Setting up a transfusion Prescribe Transfusion on IV chart- State units to be given- Rate of each unit (slowest approx 4 hours)- Give saline (100ml+) before (to keep cannula ‘open’) and after transfused units to ‘wash through’ the line.- Frusemide (40mg) is often given with each or every other unit (IV or PO) to stop potential fluid overload. Not required when patient is hypovolaemic- All patient details MUST be correctly charted.
31Blood Transfusion It takes TWO to check details of blood unit Check details on the unit of blood against those written on the form against patient’s wrist band. ALL MUST BE CORRECT! (Recent advance = bar code devices)DO NOT PUT UP UNITS WHICH YOU ARE NOT HAPPY ABOUT!Check any queries with the laboratory or the haematologist on-call.
32Blood Transfusion - Procedure Introduce yourself to the patientCheck patient understanding and ensure they are happy to receive blood transfusionGain verbal consentEnsure patient has venous access – will need to site cannula if no access present!Check equipment – Correct unit of blood and blood giving setWith a partner – check unit of blood details against transfusion slipCheck patient details against blood unit.Puts on glovesAttach unit of blood to giving set and run through blood correctlyAseptically attach blood giving set to cannula; Secure the giving set and cannula with bandaging.Ensure blood is flowing and set at correct rateInform nurses blood is running and to make sure routine observations are made.
33Setting up the transfusion To set up a transfusionTwo people to check detailsBlood transfusion report form; Unit(s) of bloodPatient with IV access (!) and wrist id bandSterile blood giving set
34Blood Transfusion - Acute Complications I CauseIncidence / Likely timing with regard transfusionTreatmentAcute Intravascular haemolysisABO incompatibility(Commonest cause is administrative!)1:6x105Occurs within a few mls of starting transfusion(Mortality 10%)Shouldn’t happen!STOP THE BLOOD!Supportive treatmentTreat complications – ARF and DICFebrile Non-haemolytic reactionsAnti –Leucocyte Ig orCytokines in platelet transfusionsCommonest in patients receiving multiple transfusions or previously pregnantBecoming rarer because of leucocyte depletion in many transfusion practices.Occurs towards the end of or up to hours after transfusionUnpleasant – but not life threateningParacetamol and cooling.UrticariaTransfusion contains plasma proteins or allergens causing an acute IgE mediated allergic responseOccurs with plasma and platelet rather than red cell transfusions.1 – 2% of all transfusionsPeri-transfusionMay occur recurrentlyAnti-histamines –(can be given prophylactically in known patients)Infective shockBacterial contamination of transfused bloodRare; 1:5x 105First 100mls of blood – ie earlyOften fatal!That of Septicaemia and shock – fluids, IV antibioticsAnaphylaxisAnti-IgA antibodies ?othersPatients are often IgA deficient as well!Extremely rareLife threateningA.B.C / Crash team callIV / IM adrenaline, steroids, aHistamines, OxygenNebulisers.
35Blood Transfusion - Acute Complications II Transfusion Related Acute Lung Injury (TRALI)RHS Rare; Non-cardiogenic Pulmonary oedemaCaused by donor blood containing anti-Leucocyte antibodiesOccurs at the start of the transfusionCan be life threateningTreat for(a) Acute transfusion reaction(b) Respiratory failure (ARDS), Shock and Pulmonary oedema(RHS – Rocking Horse Shit – Not Royal Horticultural Society)As Dorothy parker once said – ‘You can lead a whore to culture but you can’t make her think’)
36Blood Transfusion – Delayed Complications CauseIncidence / TimingTreatmentDelayed Red cell haemolysisRecipient IgG vs Red cell antigensOccurs in previously transfused or pregnant patients; Initial cross match will not contain IgG but subsequent cross matches should!5 – 10 days after transfusion<1:500 red cell transfusionsNo treatment per se butPatient will receive less benefit from transfusion and once present they will cause problems for future transfusionsTransfusion associated Graft versus Host disease(TA-GvHD)Immune mediated donor T-cell reaction (often occurs in immunodeficient patients)Fever, Rash, MOF, PancytopaeniaRare 1:750,000 units of cellular blood components transfused4 – 30 days after transfusionUsually fatal!Haematology specialist care requiredIn susceptible recipients – blood is subjected to Gamma irradiationPost Transfusion PurpuraAnti-Platelet antibodies(usually aHPA-1a)Immune medicated TCPPrimarily during pregnancyRHS Rare5 -10 days after transfusionOften severe TCP causing bleedingUse HPA-1a negative red cell and platelet transfusions or LDBloodHigh dose IV Immunoglobulins for 5 days0.4g / kgPost Transfusion Viral InfectionVirus (and other infective agents e.g. prions) undetected by UK screening systemHIV <1: 3x 106HBV and HCV < 1: 2 x 105Counselling and specialist advice requiredIron overloadMultiple transfusionsOne unit of blood contains 250mg of ironOnly occurs after several years of blood transfusionse.g. Chronic haemolytic diseaseDesferrioxamine – increases iron excretion
37Generic Management of Acute Transfusion Reaction Most ‘reactions’ occur within the first fifteen minutes of blood being started – this is the most important time for observations to be done. Do not hide the patient away during this time – let the nurses know transfusions are running and that they should do formal observations for the first fifteen minutes and then routinely.If a reaction occurs:-Stop the unit of blood being transfused!Ensure patient is clinically well and no other pathology is present (why are they having transfusion etc) - Treat the underlying cause of ‘reaction’; Once patient is deemed OK:-Disconnect and take down entire transfusion giving set and blood unit.Maintain venous access with normal salineCheck administrative details from transfusion forms and patient’s wrist bandContact the haematology / transfusion lab and inform them you are returning the unit of blood for testing.Take bloods – Blood film, FBC, Cultures, Clotting, Cross match sample (U&Es)If blood transfusion is essential or serious reaction occurs need further advice from haematologistNursing staff need to observe patient for signs of ‘shock’, DIC, acute renal failureThus ‘Regular’ observations of BP, Pulse, ToC, Urine output
38Re-cap of Multidimensional analysis Hopefully by now you will be familiar with using multidimensional analysis. I have included the example from module one. If you are confident using other methods this is fine but you must get the answers correct!
39Dimensional AnalysisDimensional analysis is commonly used by chemistry and physics students to ensure they don’t make basic calculation errors when using lots of values in an equation with different units; Each time one converts one unit to another we use a conversion factor, which we will call the dimensional analysis conversion factor (DACF) e.g 450g to kg – the DACF = 1000g / 1 kgThus 450g / Xkg = 1000g / 1 KgXKg = 450g x 1 Kg1000g= KgDimensional analysis ensures that both sides of an equation are ‘singing from the same hymn sheet’. I.e. The units on both sides are the same. By cancelling the units above and below the line, the units yu are left with on one side should equal those of the value you are seeking. If they don’t match, you have mucked up somewhere! It will not ensure your maths is correct.
401 case / 4 six packs = 5 cases / x six packs = 20 six packs - Dr Michael Baker – a teacher with a similar outlook on education!Dimensional analysis for party planning…If you have ever had a party you have used dimensional analysis. The amount of beer (or soft drinks) and munchies you will need will depend on the number of people you expect. For 30 people you may estimate you need to go and buy 120 bottles of beer and 10 large pizzas (obviously not a medic party!) How did you guestimate these numbers? Here’s the dimensional analysis.4 bottles / person and 1/3 of a pizza per person30 persons x (4 beers) = 120 beersperson30 persons x (0.333 pizza) = 10 pizzasBut should you buy beer in six packs or cases? – 1 case = 4 six packs = 24 Beers120 beers x 1 six pack x 1case = 5 cases6 Beers six packs1 case / 4 six packs = 5 cases / x six packs = 20 six packs
41To calculate drip rates / transfusion rates Blood transfusions are run through specific giving sets with a filter included in the chamber and wide bore tubing.You can NOT run them through a normal giving set as without the filter the blood will coagulate.Likewise you should NOT run fluids such as saline and dextrose through a blood giving set unless it is during or after a blood transfusion.
42To calculate drip rates / transfusion rates For any giving set the tubing will have its own drop factor. This is the number of drops in 1ml.The drop factor is written on the packaging and is dependent on the bore of the tubing.For reasons unbeknown to me the units of drop factor is gtt / minute.Common drop factors are 10, 15 and 20 gtt / minPaediatric drips commonly have a drop factor of 60 gtt /minSaline and Dextrose are commonly run through 10 gtt / min tubing whereas blood is commonly run through 20 gtt / minute tubing
43To calculate drip rates / transfusion rates To calculate the drip rate (drops / minute)Drip Rate gtt = Volume to be infused (ml) x Drop Factor (gtt/ml)min Time (minutes)1 unit of blood is approximately 400ml in volumeE.g. A unit of blood is prescribed to run over 2 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min)?(See next slide for answer and calculation)The calculations used here are similar to those used for crystalloid transfusions – see module (4)
44Example one – Calculate the Transfusion rate E.g. A unit of blood is prescribed to run over 4 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min) ?Drip rate = 400 ml x 20 gtt ; Drip Rate is drops / minute4 hour 1mlThus Drip Rate = 400ml x 20 gtt x 1 hour4 hour 1 ml minutesBy multidimensional analysis units are correct (drops / minute)Drip Rate = 100 / 3 = 33 drops / minuteDrop rate is rounded up or down to the nearest dropIn the clinical setting to be able to count drops / minute it is sensible to have a number divisable by 4 - Thus you would set this drip at 32 drops per minute
45Please try the following calculations – They should be included in your folder A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct?(2) A 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit?
46X gtt / min = 400ml x 20 gtt x 1 hour 4 Hr 1 ml 60 minutes A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct?Using Drip Rate = Volume to be Infused x Drop factor Time in minutesX gtt / min = 400ml x 20 gtt x 1 hour4 Hr ml minutesThe drip should be running at 33 gtt/ min – so it needs to be re-set.
47Using Drip Rate = Volume to be Infused x Drop factor Time in minutes A previously well 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit?Using Drip Rate = Volume to be Infused x Drop factorTime in minutes60 gtt / min = 400 ml x 10 gtt x 1 hourX hour ml minutesX hours = = 1.11 hours / unit3600Thus for 6 units = 1.11 x 6 = 6.67 hoursPlus 5 minutes between units 1,2; 2,3; 3;4; 4,5; 5,6 = 25minutes = 0.42 hoursTotal transfusion (or confusion) = 7.1 hours
48Converting drip rate (gtt /min) to ml /hour In high dependency areas caring for critically ill patients it may be necessary to know the infusion rate in ml/hour – this is important in setting infusion pumps and in calculating fluid balance.E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml?
49If there are 40 drops in one minute then in 1 hour E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml?If there are 40 drops in one minute then in 1 hour40 drops = X drops thus X = 40 x 60 = 2400 drops / hour1 minute minutesIf the giving set has drop factor of 20 drops/ 1 ml20 drops = 2400 drops thus Xml = = 120 ml / hour1 ml X mlTherefore one could set an infusion pump to deliver this volume or it can be factored into the fluid input /hour.
50Calculate the Transfusion rate in ml/hour A 94 yo woman is receiving a ‘slow blood transfusion for myelodysplasia. The unit of blood is being run at 60 drops / minute through a 20 gtt / ml giving set. Calculate the rate of the transfusion and comment on whether the rate is appropriate
51Too Much – Too QuicklyIf there are 60 drops in one minute then in 1 hour60 drops = X drops thus X = 30 x 60 = 3600 drops / hour1 minute minutesIf the giving set has drop factor of 10 drops/ 1 ml20 drops = 3600 drops thus Xml = = 180 ml / hour1 ml X mlThus the unit of blood (400ml) will run through in 400 / 180 = 2.22 hoursI.e. Too quickly for an 94 yo with myelodysplasia
52Learning Outcomes At this point you should Have read and made notes regarding the ‘who, why, where and when’ of blood transfusionBe aware of the acute and chronic complications of transfusionBe aware of the steps regarding ordering and setting up a blood transfusionBe able to order a cross match for a patientBe able to prescribe a blood transfusionBe able to calculate the correct infusion rate in drops/min and ml / hourIf you are unable to achieve all of these outcomes at this point you will need to continue to practice the skills and re-visit the webpages to refresh your knowledge
53Recommended websites and References References to follow