1. Respond Deliver & Enable Blood Transfusion Update for General Practice Hospital Transfusion Team RD&E rde-tr.HTT@nhs.netrde-tr.HTT@nhs.net.

2. Respond Deliver & Enable Welcome to Transfusion Training! The aim of this training is to support you as General Practitioners in making appropriate, safe decisions when you request and prescribe blood There is a national mandatory requirement for all involved in the process of blood transfusion to have regular 3 yearly training, which this training will fulfil

3. Respond Deliver & Enable Update from the Hospital Transfusion Team.. The RD&E transfusion laboratory is now cross matching a maximum of 2 units for transfusion for one patient in 24 hrs This is in response to recent audit and National Guidance Some patients, particularly transfusion dependent haematology patients, may have a higher transfusion requirement, please discuss with the patient’s consultants if you feel you need more than 2 units All transfusion requests will be reviewed by a member of the Hospital Transfusion Team

4. Respond Deliver & Enable SECTION 1 When is transfusion appropriate? How many units should I prescribe?

5. Respond Deliver & Enable Indication for transfusion Haemoglobin trigger levels for transfusion are well established They are one of the reasons that there has been a national 20% reduction in the use of RBC transfusions in the last 15 yrs. There is increasing evidence in patients who are not acutely bleeding that a restrictive transfusion policy reduces patient mortality and morbidity

6. Respond Deliver & Enable Is transfusion appropriate? A 78yr old patient with a chronic normochromic normocytic anaemia has a haemoglobin of 85g/l. What do the national guidelines say? Should you transfuse?

7. Respond Deliver & Enable Transfusion in Patients who are not acutely bleeding National Guidance ( NBTC 2013) In chronic anaemia aim to maintain haemoglobin levels so as to prevent symptoms of anaemia Transfusing when haemoglobin levels fall below 80g/l is appropriate for many patients

8. Respond Deliver & Enable Some patients will do better with higher oxygen delivery….. Haematology or Renal patients often have a higher transfusion requirement, be guided by symptoms and consultants Patients who have cardiovascular disease have higher oxygen requirements to remain symptom free, aim to keep haemoglobin levels above 80g/l For chemotherapy patients maintain Hb above 80-90g/l For radiotherapy patients maintain Hb above 100g/l As ever be guided by your patient’s symptoms rather than their numbers

9. Respond Deliver & Enable So in this patient….. The haemoglobin is not at the trigger level for transfusion but clearly the decision must be made on individual symptoms If his symptoms do warrant transfusion, one unit is all he is likely to need.

10. Respond Deliver & Enable Is transfusion appropriate? 78 yr old man with a microcytic anaemia of 72 g/l, who is slightly breathless on exertion The anaemia is being fully investigated He is intolerant of oral iron Should you arrange a transfusion?

11. Respond Deliver & Enable Iron Deficiency Anaemia (IDA) In IDA, patients need iron rather than blood unless there are symptoms of end organ failure IV iron now much safer to give and readily available within the RD & E (AMU will arrange) 1 gram of iron can be infused over 60 minutes, this is the amount of iron contained in 4 units of blood

12. Respond Deliver & Enable So in this patient….. Arrange for patient to have an intravenous iron infusion If you feel patient’s symptoms mean that you need to increase his haemoglobin more quickly than the 7-14 days it will take with intravenous iron, then a 1 unit transfusion followed by iv iron may be appropriate

13. Respond Deliver & Enable How many units to prescribe? An 84 yr old lady with a longstanding anaemia of chronic disease has a haemoglobin of 70g/l and is feeling breathless and a bit dizzy on standing. She weighs 50 kg How many units should you prescribe?

14. Respond Deliver & Enable Why give 2 when 1 will do? The rule that 1 unit of blood increases Hb by 10 g/l only holds for someone of 70 kg In a ‘little elderly lady’ weighing 50kgs, the Hb may rise by 15 to 20 g/l after 1 unit It is very rare to need to transfuse anyone to over 100 g/l

15. Respond Deliver & Enable So in this case….. She has a haemoglobin of 70g/l and given her size every unit will increase her haemoglobin by at least 15g/l You could bring her in for 1 unit and check her haemoglobin and then bring her in again for another unit if needed, but in the community this may be difficult and you may want to give her 2 units to bring her Hb up to 100g/l If you prescribed 3 units, you would over transfuse her and unnecessarily put her at risk of cardiac overload and other transfusion reactions

16. Respond Deliver & Enable SECTION 2 The practicalities of arranging a blood transfusion

17. Respond Deliver & Enable Patient Consent to Blood Transfusion Where possible patients should have the risks, benefits and alternatives to transfusion explained to them Record reason for transfusion consent in notes Provide written information, leaflets available within all community hospitals

18. Respond Deliver & Enable Risks of blood transfusion 1 : 1 300 samplesSample does not contain the blood of the person named on the sample label 1 : 10 000 unitsSevere transfusion reaction 1 : 13 000 unitsBlood component transfused to the wrong patient 1: 1.3 million unitsHepatitis B 1: 6.5 million unitsHIV/AIDS 1: 28 millionHepatitis C unknownCJD Transfusion is very safe in UK but preventable death and major morbidity still occur Inappropriate transfusions put patients at unnecessary risk of identification errors, transfusion reactions and infections

19. Respond Deliver & Enable Taking the blood…… Ask the patient for their name and date of birth, let them tell you. If they are inpatients always check the ID band Always write details on the tube straight away and AT the bedside Only take blood and label samples for one patient at a time

20. Respond Deliver & Enable Patient Identification Errors We detect an average of 6 Wrong Blood in Tube (WBIT) incidents per year WBIT means that the blood in the sample bottle is not the blood of the patient whose details are written on the label There are 2 main causes for this: –Failure to identify the patient correctly –Failure to label the sample at the bedside

21. Respond Deliver & Enable The Request Form….. This is your way of communicating with our lab staff PLEASE: Tell us the name of the GP making the request so if there are any difficulties we can contact you Tell us why you are transfusing the patient ( not just low hb..) and their pre transfusion haemoglobin level Tell us where the blood needs to be sent to and what day/time it is needed, we will be able to alert you earlier if there are any difficulties

22. Respond Deliver & Enable Completing the request form….. Use patient sticker or hand write: Hospital or NHS number Surname Fore name Date of birth Please add requesting Gp name, so that we know who to contact Complete special requirements Number of units when and where transfusion will take place Meaningful reason for transfusion not low Hb if possible…

23. Respond Deliver & Enable Special Requirements: Irradiated Blood Irradiating donated blood removes any remaining leucocytes, this eliminates the risk of Transfusion Associated Graft vs Host disease This is a rare but frequently fatal complication of blood transfusion Some patients because of present or prior treatment or illness are at increased risk of TaGvH disease and require irradiated blood

24. Respond Deliver & Enable In the community, consider if patient has history of : –Chemotherapy with purine analogues eg fludarabine –Hodgkin's disease either in the past or present –Bone marrow transplant –Has been treated with anti-CD52 antibodies or anti-thymocyte globulin This list is now available on the back of transfusion forms There is a system for identifying these patients at diagnosis and a warning system on the laboratory computer, ask the lab if you are not sure Who needs Irradiated blood?

25. Respond Deliver & Enable What about the Cytomegalovirus box?? CMV screened red cells & platelets are only needed for –neonates and intra uterine blood transfusions –Planned transfusions during pregnancy –Some granulocyte transfusions In the community you are pretty safe to tick the no box!

26. Respond Deliver & Enable Taking the sample.. How many do you need to take? The RD&E needs confirmation of a patient’s ABO group from 2 separate samples to reduce the risk from mislabelled samples Over 90% of patients already have a group recorded on our computer system and just need 1 new sample for cross match If you are unsure of how many samples to take please ring the Transfusion Laboratory If taking 2 samples they should be taken from 2 venepunctures with 2 SEPARATE attempts at patient identity, please use 2 forms with time difference on samples

27. Respond Deliver & Enable Taking the sample.. How far in advance of the transfusion can it be taken? The standard sample validity time is 72 hours between sampling and transfusion If no pregnancy or transfusion within previous 3 months then the sample validity time extends to 7 days In transfusion dependent haematology patients it may be possible to waive the 72 hr rule after discussion with their consultant

28. Respond Deliver & Enable Time to blood transfusion from taking blood sample……. Day 1: Blood sample taken in Community arrives in lab on transport at 3pm when the blood sample will be cross matched but not in time for the routine transport out which leaves at 4 pm each day Day 2:Blood transported to Community Hospital, leaving RD&E at 4 pm Day 3:Blood Transfusion

29. Respond Deliver & Enable Section 3 Safe Administration of blood: Blood Transfusion Reactions

30. Respond Deliver & Enable A patient is 10 minutes into the start of a blood transfusion She complains of feeling itchy, develops an urticarial rash and feels light headed The nurses contact you for advice What is this likely to be and what should your first action be?

31. Respond Deliver & Enable This is likely to be an acute transfusion reaction Key action is to STOP the transfusion Follow the Transfusion Reaction Chart which is available on the ward The on call haematologist may need to be involved

32. Respond Deliver & Enable Acute Transfusion Reactions Within 24 hrs of transfusion 1.Febrile reactions, often mild 2.Allergic reactions ranging from urticaria to anaphylaxis 3.Acute Haemolytic Reactions eg ABO incompatibility 4.Bacterial contamination range from mild pyrexia to septic shock 5.Transfusion - associated circulatory overload (TACO) 6.Transfusion – related lung injury (TRALI)

33. Respond Deliver & Enable A frail 85 year old man is having his 3 rd unit of blood and starts to feel breathless What should you do? What is the likely diagnosis? How can you try and prevent this happening again?

34. Respond Deliver & Enable This is likely to be Transfusion Associated Circulatory Overload (TACO) This is defined as acute or worsening pulmonary oedema within 6 hours of a blood transfusion It is now the leading cause of mortality related to blood transfusion in the UK ; 9 deaths and 32 patients admitted to HDU last year

35. Respond Deliver & Enable What should you do? Stop the transfusion Assess patient as per Blood Transfusion Reaction protocol If you think this is TACO, treat as Left Ventricular failure, the patient will need a CXR and admission to RD&E or NDDH Contact the Consultant Haematologist on call

36. Respond Deliver & Enable Who is at risk of TACO? Patients over 70 yrs old of low weight with cardiac or renal failure or a low albumin are higher risk of TACO In these patients: –Clearly record reason for transfusion, is this transfusion really necessary? –Assess patient before transfusion and if at risk transfuse slowly, consider diuretic cover –Ask nursing staff to observe for signs of fluid overload –Single unit transfusions are advised

37. Respond Deliver & Enable Delayed Transfusion Reaction A patient who had a transfusion 8 days ago presents to you feeling generally unwell, with dark urine and loin pains Apart from a UTI, what else would you consider?

38. Respond Deliver & Enable This could be a delayed transfusion reaction.. These occur up to 14 days post transfusion They present with features of haemolysis, with a less than expected rise in haemoglobin levels post transfusion, jaundice, fever, haemoglobinuria, acute renal failure Initial blood tests should include a repeat Group and Save, also requesting a DAT (Direct Antiglobulin Test) on the same form, FBC and LFTs. Easy to miss, treatment is supportive, refer for investigation to clarify nature of antibody for future transfusions

39. Respond Deliver & Enable 5 Key Points….. 1.Transfuse appropriately using haemoglobin trigger levels 2.Try not to over transfuse, remember size does matter 3.Use oral or iv iron in patients with iron deficiency rather than blood transfusion 4.Identify patients correctly; ‘Right Blood Right Patient every time’ 5.Transfusion related Circulatory Overload (TACO) is highest cause of mortality from transfusion

40. Respond Deliver & Enable Thank You!! Hospital Transfusion Team RD&E rde-tr.HTT@nhs.netrde-tr.HTT@nhs.net.