2. Transfusion Christine Sullivan Transfusion Practitioner

3. The Transfusion Process How do we get from this… …to this…

4. The Transfusion Process …without this…

5. BLOOD PRODUCT TRANSFUSION IS……? A liquid Transplant!

6. Panic leads to inappropriate transfusion. A 62 year old female patient was admitted in a collapsed state with malaena and a non confirmed episode of haematemasis. A Hb result on a blood gas analyser was 15g/dL. A decision was taken to delay surgery and to do a gastroscopy and colonoscopy. Notwithstanding, the patient was transfused with 3 units of ‘emergency O negative’ blood; the post-transfusion Hb was 18.6g/dL. She developed cardiac failure and subsequently died.

7. Indications for Red cells 1 Unit of red cells will increase Hb by approx 1g/l 1 Unit of red cells will increase Hb by approx 1g/l Hb <7 Hb <7 CVA/cardiac problems Hb <10 CVA/cardiac problems Hb <10 Symptomatic Symptomatic Massive Haemorrhage Massive Haemorrhage

8. Indications for Platelets Each pool of platelets will increase count by approx 30 -40 Each pool of platelets will increase count by approx 30 -40 Spontaneous major haemorrhage rare if platelet count is above 20 X 10 9 /l Spontaneous major haemorrhage rare if platelet count is above 20 X 10 9 /l Common triggers Common triggers Major Surgery < 100 x 10 9 /l Major Surgery < 100 x 10 9 /l Minor procedure < 50 X 10 9 /l Minor procedure < 50 X 10 9 /l Haematology patients < 10 X 10 9 /l Haematology patients < 10 X 10 9 /l Certain contraindications Certain contraindications ITP ITP

9. Indications for FFP FFP issued according to patient weight- 12-15ml/kg FFP issued according to patient weight- 12-15ml/kg Patient is bleeding and INR > 1.4 Patient is bleeding and INR > 1.4 Not to be used as reversal for over coagulation prior to surgery! Not to be used as reversal for over coagulation prior to surgery! Order 30 mins prior to needing it Order 30 mins prior to needing it Takes 30 mins to thaw Takes 30 mins to thaw Prescribe all units given by lab Prescribe all units given by lab Units MUST be prescribed individually! Units MUST be prescribed individually!

10. Transfusion Time Red cells Red cells Max 4 Hours but can transfuse over 2-3 Max 4 Hours but can transfuse over 2-3 Cost £124.85 Cost £124.85 FFP FFP Max 4 Hours Max 4 Hours Cost £27.66 Cost £27.66 Platelets Platelets 30 minutes 30 minutes Cost £227.45 Cost £227.45 Cryo Cryo Usually given stat Usually given stat Cost £189.21 Cost £189.21

11. All the above is irrelevant if certain other procedures are not carried out correctly Sampling Sampling Communication with laboratory Communication with laboratory Knowing your products and what they do and when to use them Knowing your products and what they do and when to use them

12. Sampling Right Patient Right Blood Right Details

13. Verify with patient their name and date of birth Verify with patient their name and date of birth Confirm details on Wristband Confirm details on Wristband Bleed one patient at a time Bleed one patient at a time Label sample tubes at bedside Label sample tubes at bedside Hand write details on sample Hand write details on sample Do not take samples from a drip arm! Do not take samples from a drip arm! NO ADDRESSOGRAPH LABELS! NO ADDRESSOGRAPH LABELS!

14. 92 year old women admitted with GI bleed and CVA 92 year old women admitted with GI bleed and CVA Hb 8.1g/dl Hb 8.1g/dl Transfusion of 4 units given Transfusion of 4 units given Patient developed cardiac problems and died shortly afterwards Patient developed cardiac problems and died shortly afterwards Post transfusion Hb 17.6g/dl Post transfusion Hb 17.6g/dl Subsequent investigation raised the possibility that sample taken from drip arm Subsequent investigation raised the possibility that sample taken from drip arm

15. Electronic Issue Need 2 fully tested samples Need 2 fully tested samples 1 sample – historical 1 sample – historical 1 sample – current (less than 5 days old) 1 sample – current (less than 5 days old) No atypical antibodies No atypical antibodies Blood available on request within 15 minutes Blood available on request within 15 minutes

16. Communication with Lab Tell them what is going on, Tell them what is going on, Let them know how urgently you need the blood products Let them know how urgently you need the blood products Let them know if you suddenly no longer need products Let them know if you suddenly no longer need products

17. Products

18. Octaplex Prothrombin Complex Concentrate (PCC) Prothrombin Complex Concentrate (PCC) Maximum dose 3000iu. Maximum dose 3000iu. Comes in 500iu vials Comes in 500iu vialsIndications: Rapid reversal of oral anticoagulant Rapid reversal of oral anticoagulant Cerebral Haemorrhage INR >2 in patients who are taking oral warfarin Cerebral Haemorrhage INR >2 in patients who are taking oral warfarin INR>8 INR>8Contraindications: Liver disease Liver disease Recent MI Recent MI HIT(Heparin induced thrombocytopaenia) HIT(Heparin induced thrombocytopaenia) Issued after consultation with consultant Haematologist

19. Recombinant Factor V11a Dose: 90ug/kg by slow bolus 90ug/kg by slow bolus Can be repeated after 2 hours if still significant blood loss Can be repeated after 2 hours if still significant blood loss Do not give more than 2 doses Do not give more than 2 doses Indications for use: Severe peri or post operative Haemorrhage unresponsive to conventional management. Severe peri or post operative Haemorrhage unresponsive to conventional management. Continued blood loss, >200mls/hr, despite correction of coagulopathy and optimal surgical intervention Continued blood loss, >200mls/hr, despite correction of coagulopathy and optimal surgical intervention Severe Obstetric Hemorrahage which is continual despite surgical intervention Severe Obstetric Hemorrahage which is continual despite surgical intervention Used for the rapid reversal of oral anticoagulant

20. Recombinant Factor V11a cont Guidelines: More than 10 units of red cells in under 24 hours and is still significantly bleeding More than 10 units of red cells in under 24 hours and is still significantly bleeding Received at least 2 pools of platelets Received at least 2 pools of platelets Received at least one theraputic dose of FFP and/or 2 pools of Cryoprecipitate Received at least one theraputic dose of FFP and/or 2 pools of Cryoprecipitate And surgical measures to achieve haemostasis are unsuccessful. And surgical measures to achieve haemostasis are unsuccessful. Issued after consultant discussion with consultant haematologist

21. Special requirements Irradiated IrradiatedGroups Solid organ and bone marrow transplant Solid organ and bone marrow transplant Patients who have received Fludarabine or its derivatives Patients who have received Fludarabine or its derivatives Hodgkins Disease Hodgkins Disease Intrauterine Transfusion Intrauterine Transfusion Exchange transfusion Exchange transfusion

22. Special requirements CMV Neg CMV Neg Patient Groups Children under 1 year of age Children under 1 year of age Patients who have been tested and are CMV Neg (Leukaemia children) Patients who have been tested and are CMV Neg (Leukaemia children) Pregnant female requiring a transfusion pre delivery Pregnant female requiring a transfusion pre delivery Patients who are potential for Bone Marrow Transplant Patients who are potential for Bone Marrow Transplant

23. Special Requirements Clinicians continue to be unaware of the indications for Irradiated products in their patients (especially Hodgkin’s disease), fail to communicate with the laboratory and make errors in requesting and prescribing. Better communication between clinical teams ‘sharing care’ for patients is essential. Thirty-seven per cent of the patients who had received purine analogues and 16% of cases involving stem cell transplantation had been treated at another hospital but no record of their special transfusion requirement had been communicated to the local hospital or transfusion laboratory. SHOT 2005 SHOT 2005

24. E-Learning WWW.learnbloodtransfusion.org.uk 3 modules Assessments at end of each module Print off certificate

25. Questions?