BLOOD COMPONENTS
WHAT DO YOU NEED TO KNOW?
Janine Carnell
Transfusion Nurse Consultant
Eastern Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health
MYTHS AND LEGENDS
Egyptian princes, knights and royalty
bathed in it – resuscitate the sick and
rejuvenate old and incapacitated
 Warriors, hunters and Romans drank it – from
dying gladiators (such blood was especially
beneficial since the athletes were strong and
brave)
 Used as a sacrifice to the Gods by ancient
American and Mexican Indians.
 In England, blood from newly executed criminals
was a curative (prescription required).
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BLOOD TRANSFUSION HISTORY
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In 1667, Dr. Jean-Baptiste Denys (physician to King
Louis XIV of France) transfused the blood of a sheep into a
15y.o. boy who survived the transfusion (small amount)
The first successful human-to-human blood transfusion
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Many other examples
Karl Landsteiner discovered A, B + C (O) groups 1901.
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1818-1829 by eminent British obstetrician and physiologist
James Blundell (PPH: husband to wife).
5 out of 10 of his subsequent transfusions were successful.
4th major group (AB) reported by Decastello and Sturli in 1902.
Around 1937, discovery of the Rhesus blood group system – which
was found to be the cause of the majority of transfusion reactions
up to that time
Today, to meet the annual needs of patients, Victoria
collects approx: 250,000 blood donations, 78,000 plasma
donations and 9,000 platelet donations
WHO USES BLOOD?
RED CELLS (>200MLS)
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Treatment of clinically significant anaemia with symptomatic deficit of oxygen
carrying capacity
Replacement of traumatic or surgical blood loss
Paediatric (25-100mls) – infants, young children and intrauterine transfusion
(RCH)
Special Red cells - i.e. irradiated, washed, fully phenotyped, CMV negative, whole
blood, directed donations, autologous blood
Use blood of identical ABO and Rh(D) type whenever possible.
In an emergency situation, Group O Rh(D) Negative blood should be given
while the patient's blood group is being established.
One unit of red cells raises the haemoglobin concentration in an average sized adult
by approximately 10 g/L.
Red cells are filtered to remove most leucocytes and may be resuspended in other
additives to prolong storage.
Although important, the patient’s haemoglobin level should not be the sole
deciding factor for giving red cells.
CONSIDER
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RBC transfusion should not be dictated by a
Hb concentration alone, but should also be
based on assessment of the patient’s clinical
status.
Where indicated, transfusion of a single unit
of RBC followed by clinical reassessment is
appropriate.
HAEMOGLOBIN CONSIDERATIONS
<70 g/L Lower thresholds may be acceptable in
patients without symptoms and/or where specific
therapy is available.
 70–100 g/L Likely to be appropriate during
surgery associated with major blood loss or if
there are signs or symptoms of impaired oxygen
transport.
 >80 g/L May be appropriate to control anaemiarelated symptoms in a patient on a chronic
transfusion regimen or during marrow
suppressive therapy.
 >100 g/L Not likely to be appropriate unless
there are specific indications.
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PLATELETS
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Therapeutic – Bleeding due to decreased platelet production or
functionally abnormal platelets
Prophylaxis – rapidly falling or low platelet counts
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<10 x 109 /L secondary to cancer or chemotherapy or bone marrow failure without risk
factors
<20 x 109 /L in bone marrow failure in the presence of additional risk factors (e.g., fever,
antibiotic or evidence of systemic haemostatic failure)
Maintain >50 x 109 /L for most surgical procedures; and >100 x 109 /L for surgeries with
high risk of bleeding (e.g., ocular or neurosurgery)
Apheresis (100-400mls) – single donor
Pooled (>160mls) – 4 donations
Paediatric (40-60mls) – infants, as above
One standard dose (1 pack apheresis or 1 pooled) would be
expected to increase the platelet count of a 70 kg adult by approx
20–40 x 109 /L
NB. ALL platelets from ARCBS in Victoria are universally
leucodepleted and irradiated. Check labelling
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FFP (FRESH FROZEN PLASMA)
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Patients with coagulopathy who are bleeding when
specific therapy (such as Vitamin K or factor concentrates
are unavailable)
To replace labile plasma coagulation factors during
massive transfusion, cardiac bypass, liver disease or
acute disseminated intravascular coagulation in the
presence of bleeding and abnormal coagulation
Double split (250-334mls)
Triple Split (250-310mls)
Paediatric (~60-80mls) is separated from a single unit of whole blood
and then divided into 4 packs. Reduce donor exposure and minimise
product wastage
Volume depends on clinical situation, patient size and
laboratory tests.
General guide is 10 -15mL/Kg per dose.
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Given in addition to Vit.K in warfarin overdose
Warfarin Reversal Guidelines (Vit.K, PTX, FFP)
CRYOPRECIPITATE
Cryo (10-40mls)
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Treatment of fibrinogen deficiency with clinical bleeding, an invasive
procedure, trauma or disseminated intravascular coagulation
Massive transfusion
Apheresis (60mls) 1 unit of cryoprecipitate apheresis is
approximately equivalent to 2 units of cryoprecipitate derived from
whole blood
A common dose for fibrinogen replacement is 30–40 mL
cryoprecipitate for each 10 kg patient body weight (~5 – 10 units)
Prepared by thawing FFP and recovering the precipitate. The coldinsoluble precipitate is refrozen.
It contains most of the factor VIII, fibrinogen, factor XIII, von
Willebrand factor and fibronectin from FFP.
BLOOD MANAGEMENT GUIDELINES
NHMRC, ASBT, NBA
6 MODULES
Module 2: Perioperative
 Minimise requirement
 Promote appropriate use
Identify high risk patients, and develop a specific
management plan ahead of time
Clinical Guidance
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Effect of anaemia on outcomes
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Effect of blood transfusion on outcomes
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Cessation of medications that affect haemostasis
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Peri-operatvie strategies to minimise blood loss
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Prevent hypothermia, positioning, deliberate hypotension, cell salvage
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Triggers for transfusion – coagulation parameters
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Anaesthesia and Patient Blood Management
BLOOD MANAGEMENT GUIDELINES
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Pre-Op management
Anaemia – optimise Hb and iron stores
Haemostasis management – warfarin, aspirin, NSAIDs
considerations
Blood Conservation Strategies
Pre-op
Pre-operative Autologous Donation (PAD)
Intra-op Acute Normovolaemic Haemodilution (ANH)
Cell Salvage
Post-op Cell Salvage
Appropriate transfusion practice
Transfuse in accordance with clinical practice guidelines
INDICATIONS FOR BLOOD IN THEATRE
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Elective surgery– well planned
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Emergency – chaotic
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Acute blood loss
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Obstetric – blood loss unpredictable (intra-op, post-op)
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Hb levels and surgery
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Levels 70-100g/L – transfusion likely to be appropriate if major blood
loss or S/S of impaired O2 transport
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Bleeding disorders (acquired/congenital) – liver disease, aspirininduced platelet dysfunction, DIC, thrombocytopaenia, haemophilia
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Anti-coagulated patient – be aware
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MBOS – Maximum Blood Order Schedule – local hospital policy
e.g. Arthroscopy (nil), Caesarean (G+S), Open Prostatectomy (2units)
RISKS IN THEATRE
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Checking remains VITAL
Emergency or Elective
 Crossmatched or Emergency Uncrossmatched
 Unconscious or Unidentified patient
 Local hospital policy
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Source - Toonpool.com
Remote or Satellite fridge
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Must have a detailed register of products in and out
Audit trail between Blood Bank and Theatre
Alarmed, monitored, maintenance schedule
Rapid access
Protection from public
Multiple theatres – multiple units in fridge
CURRENT RISKS
TRANSFUSION TRANSMITTED INFECTION
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“Australia has one of the safest blood supplies in
the world in terms of viral safety.” – ARCBS
Risks of Transfusion-transmitted Infection Calculated on Blood Service Data
Agent and testing standard
Window period
Estimate of residual risk ‘per unit’
HIV (antibody + NAT)
5.6 days
Less than 1 in 1 million
HCV (antibody + NAT)
3.1 days
Less than 1 in 1 million
HBV (HBsAg + NAT)
23.9 days
Approximately 1 in 764,000
HTLV 1 & 2 (antibody)
51 days
Less than 1 in 1 million
vCJD [No testing]
Malaria (antibody)
Possible, not yet reported in Australia
7–14 days
Less than 1 in 1 million
Notes: vCJD=variant Creutzfeldt-Jakob Disease; (a) The risk estimates for HIV, HCV, HBV and HTLV are
based on Blood Service data from 1 January 2010 to 31 December 2011.
Source – ARCBS website July 2012
INFORMED CONSENT
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Informed consent for transfusion means a documented dialogue has
occurred between the patient and a prescriber :
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The reason for the proposed blood product transfusion.
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The nature of the proposed blood product transfusion – what is involved
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The risks and benefits of the blood product as well as the risks or consequences of
not receiving the product.
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The availability and appropriateness of any other blood management strategies.
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An opportunity to ask questions.
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Use of a competent interpreter when the patient is not fluent in English.
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Use of written information or diagrams where appropriate.
Be aware of local hospital policy
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Specific consent form? Generic Consent form? Request slip? Progress Notes?
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Who signs? Doctor? Patient? Witness?
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Refusal?
DOCUMENTATION – BLOOD
TRANSFUSION
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Variation in forms and requirements across Health Services
Know hospital policy
 Request slip
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Blood release form
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Specific blood obs, what is documented in notes…
Adverse event form / Transfusion Report Form
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Details of component, patient ID, crossmatch compatibility…
Observation charts, Fluid Balance Charts, Progress Notes
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Date, timing, terminology, special requirements, urgency…
Compatibility report form
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Where, what, who…
IV orders/Prescription for blood – specific, detailed
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Patient details, components required, urgency, modifications, indications,
prescribers and collectors signatures…
Reactions, errors, also consider Hospital incident reporting systems
Consent requirements
EQUIPMENT – FILTERS
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Stored blood contains blood clots and particles that are potentially fatal
to the recipient.
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This can cause pulmonary complications and death
It is essential that there is an integral in-line filter in the giving set to
administer a blood product
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This filter (170-200 micron) removes clots and small clumps of debris that may form
during collection and storage.
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All red cells and platelets issued by the Blood Service are leucocyte
depleted
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Therefore additional bedside leucocyte depletion filters are NOT required.
Microaggregate filters (pore size 20-40 microns) are intended to remove
microscopic debris from stored red blood cells.
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There is no evidence from controlled trials that they offer clinical benefit and their
use is not generally recommended.
EQUIPMENT – IV LINES
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IV Lines
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Must contain an inline filter (mesh in/above the drip chamber)
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Primed with normal saline or the blood component
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Must not be piggy-backed onto another line
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Attachment to extension tubing on an IV cannula/multi-lumen venous access
device is acceptable
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How many units can be put through a single IV line?
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Any number provided the flow remains adequate – if the line becomes clogged – change it
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Usually the entire transfusion episode
Must be changed when transfusion is complete/every 12 hours if not yet
complete
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reduce the risk of bacterial growth occurring
Generally speaking – if there is mesh in/above the drip chamber – this is an
inline blood filter and you DO NOT need any additional filter
IV FLUIDS
Compatible
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N/Saline
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4% albumin
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Plasma protein fractions
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Incompatible
x
Calcium containing
solutions (e.g. Hartmann’s,
Haemaccel) – may cause
clotting in line
x
5% dextrose – may cause
red cells to haemolyse
x
Most medications – need to
flush the line before and
after administration
ABO compatible plasma
Morphine,or Ketamine or
Pethidine (diluted in
normal saline)
Gelofusine
The only IV fluid universally compatible with blood components is
0.9% sodium chloride (normal saline)
EQUIPMENT
PUMPS, PRESSURE DEVICES, RAPID INFUSERS,
SYRINGE DRIVERS
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Pumps
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may be used to prevent problems with slow flow rates or clogging
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paediatric patients, or those at risk of fluid overload
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PICC, CVAD
monitored hourly throughout the infusion to ensure that expected volume is delivered
Pressure Devices and Rapid Infusers
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used with large volumes of red cells in the setting of critical bleeding
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usually also warm the red cells
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Must be monitored at all times during use
Syringe Drivers
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Paediatric use –need to ensure that blood passes through 170-200micron filter
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Continuous transfusion of coagulation factors
EQUIPMENT
BLOOD WARMERS
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Not usually required in routine transfusions
The use of a blood warmer is often advised for:
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Large volume rapid transfusions of;
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>50 mL/kg/hour in adults or
>15 mL/kg/hour in children
Exchange transfusions
Plasma exchange for therapeutic apheresis in adults.
Intrauterine transfusions, at the discretion of the feto-maternal
specialist
Patients with clinically significant cold agglutinins
Red cells must not be warmed above the set point
temperature of the approved device, commonly 41°C.
DO NOT warm blood in hot water, microwave, radiators or
under your arms!
PRE-TRANSFUSION CHECK
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The last place we can make sure we are giving the right blood to
the right patient
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Consequences of failure in checking process:
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Right Blood – lucky it arrived for the right patient
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Wrong blood – compatible – good luck
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Wrong component – (e.g. CMV negative, irradiated etc.. ) Puts the
patient at risk of adverse event – sometimes this can be delayed
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Wrong blood – incompatible – this can result in severe transfusion
reactions and even death
PATIENT IDENTIFICATION
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Local hospital policy
No ID Band = No Blood?
In emergency situations, a process should be in place for
cases where a patient is unable to be identified
Hospitals must have a written policy on the requirements
for patient identification
Many health services will specify:
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Patient ID – Surname, given name, DOB, UR number
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Additional identifiers e.g. gender, address, Medicare number
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Neonates – 2 ID bands?
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Unconfirmed identity – name changes – “unknown female”
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2 approved staff members must carry out the Patient ID check
prior to blood transfusion
PRE-TRANSFUSION CHECK
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If ANY discrepancy – DO NOT transfuse
All done at the BEDSIDE
 Blood
Bag
 Patient ID
 Documentation
OBSERVATIONS
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Temperature, pulse, respiration rate and blood pressure MUST be
measured and recorded :
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Prior to the start of each individual blood component pack administered
15 minutes after commencing administration of each blood component pack
When administration of each blood component pack is completed
There is no consensus on subsequent frequency of routine vital sign
measurement during transfusion, however many institutions stipulate hourly
measurements, after the initial 15 minute period, until completion of the
transfusion.
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Regular visual observation throughout the transfusion is essential
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Blood Pressure, Temperature, Pulse, Respiratory Rate
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Baseline
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15 minutes
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Hourly from commencement time
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Stop time
Remember – most transfusion reactions occur within the first 15
mins of transfusion
TRANSFUSION RATES
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The infusion rate for blood products depends on the clinical
context, age and cardiac status of the patient.
In stable, non-bleeding adult patients typical administration
durations are:
Red cells
 Platelets
 FFP
 Cryoprecipitate
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60-180 minutes per unit
15-30 minutes per standard adult dose
30 minutes per unit (i.e. 10-20mL/kg/hr)
30-60 minutes per standard adult dose
(i.e. 10-20mL/kg/hr).
Note – in an emergency you are limited only by the size of the cannula
TIME LIMITS
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Commence transfusion within 30 minutes of arrival from
Blood Bank
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If returned to the BB within 30mins it can be returned to the
fridge and then released to any other patient as required.
Once it has been at room temp for >30mins it cannot then be used
for any other patient – you then have up to 4 hrs MAXIMUM to
complete the transfusion
Transfusion must be complete within 4 hours
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Risk of bacterial proliferation greatly increases when unit is at
room temp for >4 hours
TRANSFUSION REACTIONS
Local hospital policy
 Recognise, React and Report
 Most common adverse reaction = fever
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Mild Reactions include:
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Moderate to Severe reactions include:
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Fever, rash,
Fever, hypotension/shock OR hypertension, tachycardia,
tachypnoea, wheeze, stridor, rigors or chills, nausea,
vomiting or pain (local, chest, back)
Reporting requirements
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Flow chart to follow?
Report form to complete?
Investigations required?
Documentation?
TRANSFUSION REACTION IN AN
UNCONSCIOUS PATIENT
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May occur after only 5-10 ml
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In a rapid emergency transfusion – signs may only be evident after several units
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Extra care must be taken in the unconscious patient to monitor and react to changes
in vital signs
Possible Signs of a Severe Adverse Reaction to Transfusion in
an Unconscious Patient
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Temperature rise more than 10C
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Pink or red urine (hemoglobinuria)
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Increased operative bleeding
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Hypotension
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Reduced urine output
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Tachycardia or bradycardia
NURSING MANAGEMENT
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Recognise
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React
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that signs and symptoms may be due to the transfusion
immediately STOP transfusion
assess and manage patient, follow policy
review documentation (in particular check the pt’s ID band
against blood bag and compatibility report form)
Report
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to HMO and Blood Bank
Document: (local hospital policy)
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Transfusion Report Form and/or Incident report
Progress notes
Investigations – pathology slip
TRANSFUSION REACTION FLOW
CHART
MANY OTHER RESOURCES ARE AVAILABLE
RESOURCES / ACRONYMS
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Australian Red Cross Blood Service (ARCBS)
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Australian and New Zealand Society of Blood Transfusion (ANZSBT)
http://www.transfusion.com.au/
http://www.anzsbt.org.au/
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Australasian Society of Blood Transfusion (ASBT)
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National Blood Authority (NBA) http://www.nba.gov.au/
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National Health and Medical Research Council (NHMRC)
http://www.nhmrc.gov.au/guidelines/publications/cp78
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Blood Matters Program – Department of Health
http://www.health.vic.gov.au/bloodmatters/
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Local hospital policies
QUESTIONS?
Janine Carnell
Transfusion Nurse Consultant
Eastern Health
Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital,
Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health