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Module 2 – Blood Transfusion

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1 Module 2 – Blood Transfusion

2 Introduction You 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.

3 Aims and Objectives This module is designed to direct your learning around the knowledge and skills associated with blood transfusion By the end of this module students should be Aware of the ‘when, where, why and who’ of blood transfusion Aware of the steps necessary to order a blood transfusion and the common reasons why this process fails Able to write up a blood transfusion Able to set up a blood transfusion Aware of the common complications of blood transfusion and their treatments Calculate the required drip rate for a unit of blood

4 Challenging 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 about 23 yo asymptomatic, healthy woman with menorrhagia - Hb 8.9 g/dl, MCV 73fl 86 yo asymptomatic man with occasional angina – Hb 9.6 g/dl, MCV 104fl 61 yo man with severe gram negative sepsis – Hb 7.0 g/dl, MCV 81fl 54 yo woman post hemicolectomy Hb 8.3g/dl, MCV 84fl 73 yo man presenting with acute upper GI bleed; BP 80/60, Pulse 120 thready – Hb 8.0 g/dl, MCV 101fl

5 Menorrhagia leading to iron deficiency anemia 8.9 73 No transfusion
Patient Hb (g/dl) MCV (fl) Transfusion Other Treatment 23yo female Menorrhagia leading to iron deficiency anemia 8.9 73 No transfusion FeSO4 Investigate if severe 86yo male Macrocytic anaemia 9.6 104 Investigate for macrocytosis Drugs, Alcohol, Hypothyroidism, Haemolysis 61yo male Severe G negative sepsis leading to normocytic anaemia 7.0 81 Transfuse 2 -3 units initially Treat severe sepsis – ceftazidine and gentamicin 54yo female Post-operative normocytic anaemia 8.3 84 Re-check Hb to ensure no further drop 73yo male Macrocyosis probably alcohol related with ? Varicael bleed 7.9 101 Transfusion – Xmatch 6 units; Resuscitate Urgent OGD: May also have coagulpathy and thrombocytopaenia

6 Challenging Knowledge II
Before attempting the skills in this module - List the steps you would take In order to cross match a patient for a blood transfusion To set up a blood transfusion List the common complications of a blood transfusion and their treatment.

7 Blood 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 Blood Packed Cells Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate

8 The 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.

9 Blood Transfusion Indications - I
The Sanguis Study, 1994 No consensus on who, when, where and why to transfuse a patient A lot of variation in practice – dependent mainly on the individual clinician ordering the transfusion ‘Strong suggestion that inappropriate use is widespread’

10 Indications for Blood Transfusion
Acute Anaemia Symptomatic hypovolaemia and blood loss. Peri-operative – ‘replacing losses’ Haemolysis (treat the underlying cause) Severe, critical illness.

11 Blood Transfusion Indications - II
Acute Anaemia Increase 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/ dL BUT Carson et al (1988); Stehling & Simon (1994) Patients tolerated Hb 8 – 10 g/dL No patients died with Hb ≥ 8g /dL and ≤ 500ml blood loss No data on morbidity ? Healing / recovery etc

13 Severe illness – Expensive Scare
(3) Severe and critical illness Oxygen delivery is dependent on: (a) Cardiac output (c.o.) (b) Oxygen content of blood However 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.

14 Recommendations 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!

15 Pale Mrs McPale – Hb ‘Unmeasurable’
Chronic Anaemia Transfuse according to - Symptoms - Co-morbidities - Level of Activity Correct 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.

16 Conclusions Acute Anaemia Treat Patient according to situation
- Co-morbidities - Symptoms - Cause of the Anaemia - Severity and likelihood of re-bleed Red Cell Transfusion SHOULD not be solely used as a ‘plasma expander’ – but primarily as a method to increase oxygen carrying capacity.

17 Pre – Transfusion Considerations
Does the patient need the transfusion? Does the patient want the transfusion? - Verbal consent - ? Soon to be written consent Cross 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 bleeding Local haematology policies

18 Does the patient need the transfusion?
Yes: Symptomatic anaemia Significant blood loss Anaemia / severe illness Improving Oxygen capacity of the blood No: Asymptomatic Hb ≥ 8 g/dL ‘Well’ patient receiving alternative therapies – EPO or Iron ‘Euvolaemic’ Anaemia secondary to B12 and folate deficiencies

19 Does 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 106 HBV 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.

20 Requesting 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).

21 Write 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


23 Patient Details required – apply within
Patient Details required on form Full names DOB Hospital Number Location Blood Group (if known) Previous transfusion and obstetric history Transfusion details Reason for request; Present Hb (if known) Location, Date and Time of expected transfusion Date of request Type of blood (Packed cells, whole blood, G&S only); Number of units. Doctor Details Name, Bleep number and Signature of person requesting the blood LABELS ARE NEVER ALLOWED ON THE FORMS OR THE BOTTLES

24 Sample 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 Location Take 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!

25 Setting 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 products Check 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!

26 The 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?

27 Cross 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

28 Prescribing 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?

29 Ward: Turner Hospital No:213436
Consultant: Feather Name; Kathy Lawrence DOB: 13/09/24 Weight Date Central or peripheral line Type of Infusion Fluid Volume of Infusion Fluid (ml) Drug to be added Total dose in bag Infusion Rate Doctor’s signature P Blood 1 unit 4 hours Frusemide IV 40mg After second unit After fourth unit N. Saline 100ml To flush the line 20 minutes

30 Setting 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.

31 Blood 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.

32 Blood Transfusion - Procedure
Introduce yourself to the patient Check patient understanding and ensure they are happy to receive blood transfusion Gain verbal consent Ensure patient has venous access – will need to site cannula if no access present! Check equipment – Correct unit of blood and blood giving set With a partner – check unit of blood details against transfusion slip Check patient details against blood unit. Puts on gloves Attach unit of blood to giving set and run through blood correctly Aseptically attach blood giving set to cannula; Secure the giving set and cannula with bandaging. Ensure blood is flowing and set at correct rate Inform nurses blood is running and to make sure routine observations are made.

33 Setting up the transfusion
To set up a transfusion Two people to check details Blood transfusion report form; Unit(s) of blood Patient with IV access (!) and wrist id band Sterile blood giving set

34 Blood Transfusion - Acute Complications I
Cause Incidence / Likely timing with regard transfusion Treatment Acute Intravascular haemolysis ABO incompatibility (Commonest cause is administrative!) 1:6x105 Occurs within a few mls of starting transfusion (Mortality 10%) Shouldn’t happen! STOP THE BLOOD! Supportive treatment Treat complications – ARF and DIC Febrile Non-haemolytic reactions Anti –Leucocyte Ig or Cytokines in platelet transfusions Commonest in patients receiving multiple transfusions or previously pregnant Becoming rarer because of leucocyte depletion in many transfusion practices. Occurs towards the end of or up to hours after transfusion Unpleasant – but not life threatening Paracetamol and cooling. Urticaria Transfusion contains plasma proteins or allergens causing an acute IgE mediated allergic response Occurs with plasma and platelet rather than red cell transfusions. 1 – 2% of all transfusions Peri-transfusion May occur recurrently Anti-histamines – (can be given prophylactically in known patients) Infective shock Bacterial contamination of transfused blood Rare; 1:5x 105 First 100mls of blood – ie early Often fatal! That of Septicaemia and shock – fluids, IV antibiotics Anaphylaxis Anti-IgA antibodies ?others Patients are often IgA deficient as well! Extremely rare Life threatening A.B.C / Crash team call IV / IM adrenaline, steroids, aHistamines, Oxygen Nebulisers.

35 Blood Transfusion - Acute Complications II
Transfusion Related Acute Lung Injury (TRALI) RHS Rare; Non-cardiogenic Pulmonary oedema Caused by donor blood containing anti-Leucocyte antibodies Occurs at the start of the transfusion Can be life threatening Treat 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’)

36 Blood Transfusion – Delayed Complications
Cause Incidence / Timing Treatment Delayed Red cell haemolysis Recipient IgG vs Red cell antigens Occurs 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 transfusions No treatment per se but Patient will receive less benefit from transfusion and once present they will cause problems for future transfusions Transfusion associated Graft versus Host disease (TA-GvHD) Immune mediated donor T-cell reaction (often occurs in immunodeficient patients) Fever, Rash, MOF, Pancytopaenia Rare 1:750,000 units of cellular blood components transfused 4 – 30 days after transfusion Usually fatal! Haematology specialist care required In susceptible recipients – blood is subjected to Gamma irradiation Post Transfusion Purpura Anti-Platelet antibodies (usually aHPA-1a) Immune medicated TCP Primarily during pregnancy RHS Rare 5 -10 days after transfusion Often severe TCP causing bleeding Use HPA-1a negative red cell and platelet transfusions or LDBlood High dose IV Immunoglobulins for 5 days 0.4g / kg Post Transfusion Viral Infection Virus (and other infective agents e.g. prions) undetected by UK screening system HIV <1: 3x 106 HBV and HCV < 1: 2 x 105 Counselling and specialist advice required Iron overload Multiple transfusions One unit of blood contains 250mg of iron Only occurs after several years of blood transfusions e.g. Chronic haemolytic disease Desferrioxamine – increases iron excretion

37 Generic 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 saline Check administrative details from transfusion forms and patient’s wrist band Contact 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 haematologist Nursing staff need to observe patient for signs of ‘shock’, DIC, acute renal failure Thus ‘Regular’ observations of BP, Pulse, ToC, Urine output

38 Re-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!

39 Dimensional Analysis Dimensional 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 kg Thus 450g / Xkg = 1000g / 1 Kg XKg = 450g x 1 Kg 1000g = Kg Dimensional 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.

40 1 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 person 30 persons x (4 beers) = 120 beers person 30 persons x (0.333 pizza) = 10 pizzas But should you buy beer in six packs or cases? – 1 case = 4 six packs = 24 Beers 120 beers x 1 six pack x 1case = 5 cases 6 Beers six packs 1 case / 4 six packs = 5 cases / x six packs = 20 six packs

41 To 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.

42 To 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 / min Paediatric drips commonly have a drop factor of 60 gtt /min Saline and Dextrose are commonly run through 10 gtt / min tubing whereas blood is commonly run through 20 gtt / minute tubing

43 To 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 volume E.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)

44 Example 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 / minute 4 hour 1ml Thus Drip Rate = 400ml x 20 gtt x 1 hour 4 hour 1 ml minutes By multidimensional analysis units are correct (drops / minute) Drip Rate = 100 / 3 = 33 drops / minute Drop rate is rounded up or down to the nearest drop In 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

45 Please 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?

46 X 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 minutes X gtt / min = 400ml x 20 gtt x 1 hour 4 Hr ml minutes The drip should be running at 33 gtt/ min – so it needs to be re-set.

47 Using 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 factor Time in minutes 60 gtt / min = 400 ml x 10 gtt x 1 hour X hour ml minutes X hours = = 1.11 hours / unit 3600 Thus for 6 units = 1.11 x 6 = 6.67 hours Plus 5 minutes between units 1,2; 2,3; 3;4; 4,5; 5,6 = 25minutes = 0.42 hours Total transfusion (or confusion) = 7.1 hours

48 Converting 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?

49 If 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 hour 40 drops = X drops thus X = 40 x 60 = 2400 drops / hour 1 minute minutes If the giving set has drop factor of 20 drops/ 1 ml 20 drops = 2400 drops thus Xml = = 120 ml / hour 1 ml X ml Therefore one could set an infusion pump to deliver this volume or it can be factored into the fluid input /hour.

50 Calculate 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

51 Too Much – Too Quickly If there are 60 drops in one minute then in 1 hour 60 drops = X drops thus X = 30 x 60 = 3600 drops / hour 1 minute minutes If the giving set has drop factor of 10 drops/ 1 ml 20 drops = 3600 drops thus Xml = = 180 ml / hour 1 ml X ml Thus the unit of blood (400ml) will run through in 400 / 180 = 2.22 hours I.e. Too quickly for an 94 yo with myelodysplasia

52 Learning Outcomes At this point you should
Have read and made notes regarding the ‘who, why, where and when’ of blood transfusion Be aware of the acute and chronic complications of transfusion Be aware of the steps regarding ordering and setting up a blood transfusion Be able to order a cross match for a patient Be able to prescribe a blood transfusion Be able to calculate the correct infusion rate in drops/min and ml / hour If 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

53 Recommended websites and References
References to follow

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