Transcript Transfusion_Dr Kate Pendry_Nov13

Transfusion for Medical Students
Nov 2013
Requesting blood for transfusion
• What is a group and screen test?
The patient’s blood group is checked and an antibody
screen is performed on the patient’s plasma. The
sample can be kept in the lab for up to 6 days and then
a crossmatch can be subsequently requested
• What is a crossmatch test?
The patient’s plasma is mixed with the donor’s red cells to
make sure there is compatibility. When ordering state
amount, time required, urgent / routine (look at surgical
blood order schedule for elective surgery)
Case 1: 27-year-old patient has a
massive post-partum haemorrhage
with severe hypotension.
• Emergency Gp O RhD negative blood does not
need to be crossmatched T
• Fully crossmatched blood would take 45 mins to
be made available F
• If O RhD blood is given there is no need to take a
crossmatch sample F
• Group specific blood can be made available in 1530 mins
REQUESTING BLOOD
Extreme emergency only
Pre transfusion testing
ASSESS URGENCY
On receipt
of the
the right
pre-transfusion
Choose
products
sample the following steps are
undertaken:
•Check the historical records
•Group: Identify ABO and RhD
group
Allocate
a lead
to plasma
liaise with
•Screen:
Check
for lab & porters
antibodies
•Crossmatch: Select component
COMMUNICATE
AVOID ERRORS
The patient’s serum or plasma
can beCareful
savedbedside
for up labelling
to 6 days in
case
later
cross-match
is
XM, FBC,
coag
screen – swiftly
to lab
required
Group O
Important antibodies may cause reaction
Valuable resource
~15mins from sample arriving
Group specific
ABO & RhD compatible
Important antibodies may cause reaction
Safest product if time allows
Crossmatched
Fully screened for antibodies
~45-60 mins from sample arriving
Preempt need for FFP (30mins to thaw;
12-15mL/kg = 4 units for average adult)
Preempt need for platelets
Transfusion Management of Massive Haemorrhage
Insert
Insert local
local arrangements:
arrangements:
Activation
Activation Tel
Tel Number(s)
Number(s)
•Emergency
•Emergency O
O red
red cells
cells
-- location
location of
of supply:
supply:
** Time
Time to
to receive
receive at
at this
this clinical
clinical
area:
area:
•Group
•Group specific
specific red
red cells
cells
•• XM
XM red
red cells
cells
Transfusion
Transfusion lab
lab 

Consultant
Consultant Haematologist
Haematologist 

Patient
Patient bleeding
bleeding // collapses
collapses
Ongoing
Ongoing severe
severe bleeding
bleeding eg:
eg: 150
150 mls/min
mls/min and
and Clinical
Clinical shock
shock
Administer
Administer Tranexamic
Tranexamic Acid
Acid
(1g
(1g bolus
bolus followed
followed by
by 1g
1g infusion
infusion over
over 88 hours)
hours)
Haemorrhage
Haemorrhage Control
Control
Direct
Direct pressure
pressure // tourniquet
tourniquet ifif
appropriate
appropriate
Stabilise
Stabilise fractures
fractures
Surgical
Surgical intervention
intervention –– consider
consider
damage
damage control
control surgery
surgery
Interventional
Interventional radiology
radiology
Endoscopic
Endoscopic techniques
techniques
Haemostatic
Haemostatic Drugs
Drugs
Vit
Vit KK and
and Prothrombin
Prothrombin complex
complex
concentrate
concentrate for
for warfarinised
warfarinised
patients
patients and
and
Other
Other haemostatic
haemostatic agents:
agents:
discuss
discuss with
with Consultant
Consultant
Haematologist
Haematologist
Cell
Cell salvage
salvage ifif available
available and
and
appropriate
appropriate
Consider
Consider ratios
ratios of
of other
other
components:
components:
11 unit
unit of
of red
red cells
cells == c.250
c.250 mls
mls
salvaged
salvaged blood
blood
Resuscitate, call for help
Activate Massive Haemorrhage Pathway
Call for help
‘Massive
‘Massive Haemorrhage,
Haemorrhage, Location,
Location, Specialty’
Specialty’
Alert
Alert emergency
emergency response
response team
team (including
(including
blood
blood transfusion
transfusion laboratory,
laboratory, portering/
portering/
transport
transport staff)
staff)
Consultant
Consultant involvement
involvement essential
essential
Take
Take bloods
bloods and
and send
send to
to lab
lab::
2+
XM,
XM, FBC,
FBC, PT,
PT, APTT,
APTT, fibrinogen,
fibrinogen, U+E,
U+E, Ca
Ca2+
NPT:
NPT: ABG,
ABG, TEG
TEG // ROTEM
ROTEM ifif available
available
and
and
Order
Order Massive
Massive Haemorrhage
Haemorrhage Pack
Pack 11
STOP THE
BLEEDING
Red
44 units
Red cells*
cells*
units
FFP
44 units
FFP
units
Platelets
11 dose
Platelets
dose (ATD)
(ATD)
(*Emergency
(*Emergency O
O blood,
blood, group
group specific
specific blood,
blood,
XM
XM blood
blood depending
depending on
on availability)
availability)
Give
Give MHP
MHP 11
Reassess
Reassess
Suspected
Suspected continuing
continuing haemorrhage
haemorrhage
requiring
requiring further
further transfusion
transfusion
Take
Take bloods
bloods and
and send
send to
to lab
lab::
2+
FBC,
FBC, PT,
PT, APTT,
APTT, fibrinogen,
fibrinogen, U+E,
U+E, Ca
Ca2+
NPT:
NPT: ABG,
ABG, TEG
TEG // ROTEM
ROTEM ifif available
available
Order
Order Massive
Massive Haemorrhage
Haemorrhage Pack
Pack 22
Red
44 units
Red cells
cells
units
FFP
44 units
FFP
units
Platelets
11 dose
Platelets
dose (ATD)
(ATD)
and
and subsequently
subsequently
request
request Cryoprecipitate
Cryoprecipitate 22 packs
packs
ifif fibrinogen
fibrinogen <1.5g/l
<1.5g/l or
or according
according to
to TEG
TEG //
ROTEM
ROTEM
Give
Give MHP
MHP 22
Once
Once MHP
MHP 22 administered,
administered, repeat
repeat bloods:
bloods:
FBC,
FBC, PT,
PT, APTT,
APTT, fibrinogen,
fibrinogen, U+E,
U+E,
NPT:
NPT: ABG,
ABG, TEG
TEG // ROTEM
ROTEM ifif available
available
To
To inform
inform further
further blood
blood component
component
requesting
requesting
RESUSCITATE
Airway
Stop the bleeding – TXA, PCC
Breathing
Circulation
Continuous
Continuous cardiac
cardiac
monitoring
monitoring
Team approach
Prevent
Prevent Hypothermia
Hypothermia
Use
Use fluid
fluid warming
warming device
device
Used
Used forced
forced air
air warming
warming
blanket
blanket
Emergency runner
Consider
Consider 10
10 mls
mls Calcium
Calcium
chloride
chloride 10%
10% over
over 10
10 mins
mins
Communicate with lab early and
clearly
22 packs
packs cryoprecipitate
cryoprecipitate ifif
fibrinogen
fibrinogen << 1.5g/l
1.5g/l or
or as
as guided
guided
by
by TEG
TEG // ROTEM
ROTEM
Aims
Aims for
for therapy
therapy
Know where the Emergency O
Neg is in your Trust
Aim
Aim for:
for:
Hb
8-10g/dl
Hb
8-10g/dl
Platelets
>75
Platelets
>75 xx 10
1099/l/l
PT
<< 1.5
PT ratio
ratio
1.5
APTT
<1.5
APTT ratio
ratio
<1.5
Fibrinogen
>1.5g/l
Fibrinogen
>1.5g/l
2+
2+
Ca
>1
Ca
>1 mmol/l
mmol/l
Temp
>> 36
Temp
36ooCC
pH
>> 7.35
pH
7.35 (on
(on ABG)
ABG)
Monitor
Monitor for
for hyperkalaemia
hyperkalaemia
Massive haemorrhage packs 1
and 2
STAND DOWN
Inform lab
Return unused
components
Complete
documentation
Including audit
proforma
Monitor coag tests and move to
goal directed therapy
Thromboprophylaxis should be considered when patient stable
ABG – Arterial Blood Gas
FFP- Fresh Frozen plasma
PT- Prothrombin Time
Recognise blood loss
APTT – Activated partial thromboplastin time
MHP – Massive Haemorrhage Pack
TEG/ROTEM- Thromboelastography
ATD- Adult Therapeutic Dose
NPT – Near Patient Testing
XM - Crossmatch
Stand down
v1 2011
Case 2
67-year-old male, Mr Arvind Patel, (Group O) is
admitted for elective hip replacement surgery.
His Hb is 100 g/L. Because of excessive bleeding
on the operating table the Consultant
Anaesthetist asks for 2 units of blood. The
theatre nurse collects 2 units of red cells
labelled for Mr Suhail Patel and starts
transfusion. Mr Suhail Patel is Group B.
What are the potential clinical
consequences for Mr Arvind Patel
and how would they be managed?
A. There would be no problems as it is safe to give
Group B blood to a Group O donor so the
transfusion could continue F
B. The transfusion must be stopped immediately T
C. The partially transfused bag must be returned to
the lab with a blood sample from the patient T
D. Oozing from venepuncture sites might be a sign of
a transfusion reaction T
Blood Groups
Blood
Group
Antibodies
A
Anti-B
B
Anti-A
AB
None
O
Anti-A Anti-B
RhD positive or RhD negative
A
B
AB
O
How could the error have been
avoided?
A. The theatre nurse collecting the blood should
make a note of the patient’s details so that
she can identify the correct patient F
B. The bag of blood should be checked against
the patient’s notes F
C. The bag of blood should be checked against
the patient’s wrist band T
D. There is no need to do the bedside check
when the patient is anaesthetised F
Could the transfusion have been
avoided in the first place?
A. Yes because this type of surgery is suitable
for cell salvage T
B. Yes because a Hb of 100g/L is a safe level
for a 67 year old man F
C. No because the Hb alone is not the only
trigger for transfusion T
D. Tranexamic acid would help to reduce
blood loss in this situation T
BLOOD
“1 unit RBC”
COMMON
INDICATIONS
Acute blood loss
Only with significant blood volume loss
Consider cell salvage
Anaemia Hb < 70 g/L
Likely requires transfusion
Usual time: 3hrs
4hr limit from removal from cold storage
to end of transfusion
Blood warmer for rapid transfusions
Refer to Trust Blood Transfusion Policy
Consider correctible causes
Anaemia Hb 70 - 100 g/L
Consider correctible causes
Transfuse if symptoms/needs eg IHD
Pre-operative assessment
Correction of anaemia reduces need for transfusion
MBOS (Maximum Blood Ordering Schedule)
Case 3: 17-year-old female with
heavy periods presents with Hb of
50 g/L and MCV 55 fl.
Would you give a blood transfusion?
A. Yes, I would give a blood transfusion – that
Hb level is very low F
B. No, I wouldn’t give a blood transfusion
because she will respond to an alternative
therapy T
C. Oral iron will increase the Hb by 40g in 1
week F
Case 4: A full blood count states the
platelet count to be ‘6 x 109/L’ with
an associated peripheral blood film
comment of ‘platelet clumping
seen’. A prophylactic platelet
transfusion (1ATD) is indicated as
the platelet count is <10 x 109/L. T/F
The answer is False
Fresh Frozen Plasma (FFP) is the
optimal treatment available to treat
life-threatening bleeding in patients
on warfarin T/F
The answer is False
Blood Components
Red Cells
Whole Blood
Platelets (also apheresis)
Plasma
Fresh Frozen Plasma
Cryoprecipitate
Fractionation
Factor concentrates
Eg FVIII, FIX, PCC
Immunoglobulin
Albumin
(Non UK Plasma)
BLOOD COMPONENTS
Fresh Frozen Plasma
“1 unit FFP”
Usual time: 30 mins/unit
Needs 30 mins to thaw in lab
Usual dose 12-15 mL/kg (4-6 units for average adult)
Main indications: coagulopathy with bleeding/surgery,
massive haemorrhage, TTP. Not warfarin reversal.
Cryoprecipitate
“1 pool cryoprecipitate”
Usual time: 30 mins/bag
Needs 30 mins to thaw in lab
Adults: 1 pool = 5 donor units
Usual adult dose: 2 pools (10 donor units)
Main indication:
coagulopathy with fibrinogen < 1.5 g/L
Platelets
Platelets
Massive haemorrhage
Keep platelet count above 75 x 109/l
“1failure
ATD platelets”
Bone marrow
platelet count <10 × 109/l
30 mins
or <20Usual
× 109/ltime:
if additional
risk, e.g. sepsis
Prophylaxis for surgery
1hr limit
Minor procedures 50 x 109/l;
More major
80 x 109/l;dose
CNS(ATD)
or eye
Usual
dose: 1surgery
adult
treatment
9
surgery 100 x 10 /l
Shelf-life only
7 days from donation
Cardiopulmonary
bypass
should be readily available use only
UsedPlatelets
as
prophylaxis
or treatment of bleeding / pre
if bleeding
procedure in patients with thrombocytopenia
Prothrombin Complex
Concentrate (PCC)
Plasma-derived
Vit K dependent factors: II VII IX X
For emergency reversal of life-threatening
warfarin over-anticoagulation
(do not use FFP)
Issued by transfusion lab – supply in A&E
See trust policy
Special Blood Requirements
• All patients with Hodgkin’s Disease should receive irradiated
blood T
• All patients born after 1996 should have virally inactivated,
non-UK sourced Plasma T
• All Stem Cell Transplant / Bone marrow transplant recipients
require CMV negative blood F
• Pregnant women have no special blood requirements, so
there is no need to inform the transfusion laboratory of their
pregnancy or gestation on the request form F
SPECIAL REQUIREMENTS
Fairly specific indications… Paeds, Haem, Onc, O&G…
…but “it is the responsibility of the prescribing doctor”
CMV NEGATIVE
IRRADIATED
To keep at-risk patients CMV free
(~50% of us are CMV negative)
To prevent transfusion-associated
graft versus host disease (rare)
in specific T-cell immunodeficiency cases
Children < 1yr
Intrauterine transfusions
Intrauterine transfusions
Congenital immunodeficiency
Congenital immunodeficiency
and unless known to be CMV IgG +ve:
Hodgkin Lymphoma
Pregnant women having elective
transfusion
Stem cell / marrow transplant patients
After purine analogue chemo
(eg: fludarabine)
Refer to Trust Blood Transfusion Policy
Risks of Transfusion
• The risk of transmission of HIV with transfusion of red cells is
1 in 5 million donations in the UK (0.2 per million donations).
T
• A patient becomes acutely short of breath following a
transfusion of FFP. Chest X-ray shows bilateral pulmonary
infiltrates and you give diuretics with some effect. The case
should be reported as a clinical incident via the hospital
reporting system, so it can be followed up appropriately. T
• All donors are now screened for vCJD F
Risks of Transfusion
• A patient complains of feeling unwell during their
transfusion. Their observation chart shows their
temperature, BP, pulse rate and respiratory rate
to be stable. No specific action is required. F
• A patient develops mild urticaria following a
platelet transfusion. You should administer IV
chlorphenamine (piriton) and IV hydrocortisone.
F
• Anaphylaxis is most likely to happen in the first 15
minutes of transfusion T
Serious Adverse Events from blood
transfusion reported in UK 1996-2011
Risk of giving wrong blood is much greater
than transfusion transmitted infection
TRANSFUSON REACTIONS
Mild reaction
Temp rise < 1.5°C
Urticaria
Rash
Pruritis
STOP TRANSFUSION
Review obs
Paracetamol
Chlorpheniramine?
Trust Blood Transfusion Policy
Restart cautiously
OR
STOP TRANSFUSION
Suspected
www.transfusionguidelines.org.uk
severe
reaction Right patient?
Right blood product?
Pyrexia, rigors
OR
Hypotension
Whole set to lab
Loin / back pain
New set with saline
Ask for help
Increasing anxiety
Pain at the infusion site
Full bloods as policy
Respiratory distress
Checklist (see policy)
Dark urine
Severe tachycardia
Incident form
Unexpected bleeding (DIC)
Refer to Trust Blood
Transfusion Policy
Yes
Severe / life-threatening
•Call for urgent medical help
•Initiate resuscitation- ABC
•Discontinue transfusion and maintain venous access
•Monitor the patient : TPR, BP, urinary output, oxygen sats
Anaphylaxis follow anaphylaxis pathway
If bacterial contamination policy likely start antibiotic treatment
Inform hospital transfusion department
Return unit and administration set to transfusion
Perform appropriate investigations
Not Life threatening or Severe
Resources
Trust Guidelines and Policies
Your Hospital Transfusion Team
The Transfusion Handbook
www.transfusionguidelines.org.uk