Blood Transfusion Policy
Version
8
Name of responsible (ratifying)
committee
Hospital Transfusion Committee
Date ratified
26/10/2012
Document Manager (job title)
Transfusion Practitioner
Date issued
26/10/2012
Review date
October 2015
Electronic location
Clinical Policies
Related Procedural Documents
Patient Identity Policy; Management of Adverse
Incidents and Near Misses; Management of Serious
Incidents Requiring Investigations
Key Words (to aid with searching)
Blood Platelets; Red Cells; Transfusion Reactions;
Administration; Observations; Blood products;
Administration sets; Plasma; Blood transfusion;
Blood products; Children; Neonates; Patients;
Medical records; Unconsciousness; Identification
systems; Prescriptions; Blood banks; Infusions;
Blood warmers; Blood transfusion equipment;
Patient safety; Clinical protocols; Jehovah
witnesses; Religious beliefs; Training; Blood letting;
Adverse medical reactions; Neonates; Transport;
In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked
on the document.
For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet
Blood Transfusion Policy. Issue 8. (Review date: 26/10/2015 – unless requirements change)
05/02/2016
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CONTENTS
1.
2.
3.
4.
5.
6.
7.
12
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 5
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
PROCESS ................................................................................................................................... 7
TRAINING .................................................................................................................................. 16
REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 17
Documentation – Paediactrics and Neonates ............................................................................. 23
Appendices
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1. QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for all staff involved in the process to be aware of and follow the detail of this policy.
1. Obtaining consent for a blood transfusion is a Department of Health requirement and is the
responsibility of the doctor prescribing the blood products. Do not forget the rights of the
patient to refuse a transfusion/opt for a different treatment, if available.
2. Prescription must include 4 patient identifiers, type of blood component, special requirements
(e.g. CMV negative, irradiated etc), quantity to be given, duration and rate of infusion and
signature of prescriber
3. Only suitably trained, registered practitioners can request blood products and request forms
must contain the four markers of patient identity: surname; given name; date of birth and
Hosp / District / NHS number (or ED No. / Unknown / Gender for “unknown” patients) together
with reason for transfusion, date and time required and name / signature of requesting
clinician
4. Only suitably trained medical, nursing, midwife, ODP or phlebotomy staff may take samples
for cross-matching and these must be correctly labelled with 4 points of ID at the patients’
bedside, dated, timed and signed
5. All staff collecting blood components/products must have annual update training and must
have their identity badges validated
6. Before you collect the component/product, please ensure your patient has the correct identity
band insitu
7. When collecting blood components/products, staff must check the patient’s identification
against the component label before checking out or signing for it. Do not connect any
components/products unless you have checked the details are correct yourself
8. The patient’s identification must be checked against the component label and the patient
identity band i.e. at the side of the patient before the transfusion is commenced
9. Transfusions must be given in clinical areas, where frequent visual and verbal contact may be
maintained
10. The patient’s temperature; pulse; respiratory rate; and blood pressure must be checked at the
beginning of the transfusion, 15 minutes following the start of the transfusion and again at the
end of the unit. This is the most likely time frame for an adverse reaction to occur
11. Patient’s must be told to inform a member of staff if, any time during the transfusion, they feel
unwell
12. The same giving set used for the transfusion must not be subsequently used for administering
fluids or different blood components
13. Accurate documentation of the transfusion and any adverse reaction(s) or events must be
maintained - these should be communicated to the Transfusion Practitoner and/or Blood Bank
14. Blood or blood components must not be stored in a ward / drug fridge under any
circumstances
15. Transfusions must not be given at night unless the patient is actively bleeding and should
ideally not start after 20:00hrs
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2. INTRODUCTION
Appropriate blood transfusion is an essential support to many medical treatments and is
lifesaving. Problems with the safety of blood transfusion are highlighted through the Serious
Hazards of Transfusion (SHOT) scheme. This scheme has shown that avoidable, serious
hazards of blood transfusion continue to occur in Trusts, the most common being giving the
wrong blood to patients. There are many risks to the patient and these include acute haemolytic
reactions and transfusion transmitted infections.
Blood transfusion has been associated with poor outcomes in a dose-dependent manner in
trauma patients, after major surgery and in an intensive care unit. Stringent procedures must be
followed to ensure that the correct blood is always given and that any adverse reactions are
dealt with promptly and efficiently
Procedures for ordering, prescribing and administration of blood components, as well as the
management of any complications support this clinical policy on blood transfusion. Procedures
for the documentation of transfusions in nursing, medical and laboratory records are also
provided, including the procedure for the reporting of any adverse reactions or events occurring
in relation to transfusions
This clinical policy has been revised to clarify terminology, incorporates core standards in
transfusion practice in adults, in neonatal and pediatric practice. Neonatal Intensive Care
patients are one of the most transfused groups; because of their potential normal life
expectancy they are more susceptible to the long-term effects of transfusion. Particular care
and attention must be given to neonates and children to minimise blood product use
This policy also reflects changes to legislation brought in 2005 by the European Directive
2002/98 EC as enacted by HM Government in the Blood Safety and Quality Regulations (50)
2005 and CQC requirements.
3. PURPOSE
The purpose of this policy is to:
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Provide a clear framework and guidance for safe transfusion practice, throughout
Portsmouth Hospitals NHS Trust (the Trust)
Ensure a consistent approach to the prescribing, handling and administration of blood
and blood components throughout the Trust
Ensure that all members of staff involved in any stage of the process of transfusing
blood and blood products are aware of their role and the legal aspects of this practice
4. SCOPE
This policy applies to all staff involved in the requesting, sampling, prescribing, storing,
collecting, transporting and administering of human blood and blood components, including
those who work in Primary Care Trusts supplied with blood products / blood components from
the Trust Bloodbank.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
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5. DEFINITIONS
Transfusion: blood or any of its components used to correct or treat a clinical abnormality
Blood components: red cells, fresh frozen plasma (FFP), cryoprecipitate, and platelet
concentrate
Blood Products: any drug which is manufactured using human blood components
Cold chain: the legal requirements to monitor transport and storage conditions of blood, from
donor to recipient
iPassport: the Blood Sciences electronic quality management system onto which all
documents, audits and self-inspections are registered
Maximum Surgical Blood Ordering Schedule (MSBOS): the Trust agreed maximum number
of cross-matched units or group and screen testing requirements for surgical procedures
Medicines and Healthcare Products Regulatory Agency (MHRA): An executive agency
which aims to enhance and safeguard the health of the public by ensuring that medicines and
medical devices work and are acceptably safe
National Patient Safety Agency (NPSA): An arm’s length body of the Department of Health
which leads and contributes to improved, safe patient care by informing, supporting and
influencing organisations and people working in the health sector
SABRE – Serious Adverse Blood Reactions & Events (SABRE): the MHRA reporting scheme
to which all adverse reactions and events related to blood components / products are reported
Serious Hazards of Transfusion reporting system (SHOT): the United Kingdom’s
independent, professionally-led Haemovigilance scheme; responsible for recording and
monitoring all blood component/product adverse events
Serious Incidents Requiring Investigation - Trust system for investigating Amber or Red
incidents and events
6. DUTIES AND RESPONSIBILITIES
6.1. The Hospital Transfusion Committee
The Committee is comprised of members of the Hospital Transfusion Team and
representatives from all clinical areas were a blood component/product is administered. It has
responsibility for
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Overseeing all aspects of blood transfusion practice
Promoting good transfusion practice based on national guidelines through the
provision of a robust framework to communicate information and advice
Arranging for audits of blood usage to be carried out, in line with local and national
requirements and receiving and reviewing the reports of those audits
Making recommendations to address any issues highlighted by the reports and
monitoring the implementation of the actions to prevent a recurrence
Receiving quarterly reports from the Hospital Transfusion Team regarding the
trends/themes from adverse incidents, including any variance from this policy and for
recommending any actions to address the variance
Reviewing all SHOT submissions and ensure the root causes are identified and all
necessary action taken to prevent a recurrence
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Monitoring the implementation of actions arising from the investigations of Serious
Incidents Requiring Investigation (SIRI)
Receiving the results of all audits associated with the transfusion process and
developing any required action plans to address the identified issues
Undertaking regular review of this policy and recommending any changes as
highlighted by audits or adverse incidents
Ensuring any risks associated with the transfusion process are assessed and
escalated to the Trust Risk Register
Acting as a forum to discuss advancements in transfusion practice and reviewing and
amending practices and policies in the light of those advancements
Providing, through the Chair, an annual report on all aspects of blood transfusion
practice, to the Governance and Quality Committee
6.2. Hospital Transfusion Team
The Team, which comprises the Blood Bank Manager, Clinical Lead for Blood Transfusion and
the Hospital Transfusion Practitioner, is responsible for:
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Meeting weekly to discuss current issues and incidents
Addressing and monitoring any outstanding corrective and preventative actions
Informing the decision-making process for new initiatives
Ensuring the Hospital Transfusion Committee is informed of any required audits
Reporting quarterly to the Hospital Transfusion Committee
The review and development of policies and guidelines
6.3. Hospital Transfusion Practitioner
The Practitioner is responsible for
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The investigation of all adverse incidents / near misses associated with any aspect of
blood transfusion, in conjunction with the Blood Bank Manager
Submission of reports to SHOT/SABRE, in conjunction with the Blood Bank Manager
Providing the Hospital Transfusion Committee with quarterly reports on all aspects of
transfusion practice, including adverse events
Facilitating training for all relevant staff groups
Acting as the main point of contact for staff requiring information / guidance.
6.4. Blood Bank Manager
The Blood Bank Manager is responsible for:
 Ensuring the laboratory complies with the legislation as set down in the Blood and
Safety Quality Regulations 2005 and the statutory requirements of the Department of
Health to ensure patient and staff safety
 The investigation of all adverse incidents / near misses associated with any aspect of
blood transfusion, in conjunction with the Hospital Transfusion Practitioner
 Submission of reports to SHOT/SABRE, in conjunction with the Hospital Transfusion
Practitioner
6.5. Blood Sciences Quality Manager
The Quality Manger is responsible for the quality management system: iPassport
6.6. Prescribing Clinicians
Prescribing Clinicians are responsible for:
 Obtaining and documenting consent or inability to provide consent
 Where practical - informing patients of the reasons for transfusion, their right to refuse
transfusion and of the risks and benefits
 Providing information about alternatives to blood transfusion where appropriate
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6.7. All Ward/Line Managers
All managers have a responsibility:
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To be aware of this policy and associated guidelines
Releasing staff for training
Integrating compliance into the Knowledge and Skills Framework and appraisals for all
staff
Ensuring appropriate evidence of compliance is gained during the appraisal process
Ensure their staff are aware of and understand this policy and comply with its content
6.8. All staff involved in the processes associated with blood transfusion
All staff members involved have a responsibility to:
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Attend training relevant to their role in the process
Comply with this policy at a level commensurate with their involvement
Report all adverse incidents and near misses
7. PROCESS
Note: whilst the same principles apply to all patients, regardless of age, there are some very
specific issues which relate to neonates: Appendix 3
7.1
Consent
7.1.1
Obtaining consent for a blood transfusion is a Department of Health requirement
and it is the responsibility of the prescribing Doctor to obtain and document that
consent, in accordance with Trust Policy. If the patient is unable to provide
consent, this must also be documented
7.1.2
Where practical, patients should be informed of the reasons for the blood
transfusion, the potential risks and benefits involved. They should also be informed
of their right to refuse the transfusion but must then be advised of the risks of
doing so.
7.1.3
All staff, but particularly those taking consent must be aware:
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Of the beliefs of the Jehovah’s Witness in relation to receiving any blood
component and medical alternatives, which may be applicable.
That any patient may have valid personal reasons or beliefs for not wishing
to have a transfusion
That each patient has the right to be treated with respect and staff must be
sensitive to their individual needs, acknowledging their values, beliefs and
cultural background
That an individual patient may accept different treatments such as dialysis,
cardiopulmonary bypass, organ transplants, and non-blood replacement
fluids of plasma derivatives
For guidance regarding religious or personal beliefs please see the Trust Refusal of Blood
Components Guideline
7.1.4
The patient should be provided with information about alternatives to blood
transfusion, including autologous transfusion, where appropriate
7.1.5
As well as providing this information verbally, it is best practice to provide the
patient with the information leaflets, available on all wards or from the Transfusion
Practitioner
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7.1.6
In circumstances where a patient lacks the capacity to consent and it is an
emergency or urgent situation, treatment can be provide on the basis of ‘best
interests’. However, in elective situations the healthcare professional seeking
consent must consider whether the patient has put in place either a valid and
applicable advanced decision or a Lasting Power of Attorney, which cover the
refusal of a blood transfusion. Further guidance can be obtained from the Trust’s
Legal Services Manager
8.1 Requesting Blood Components and Products
8.1.1
Only suitably trained, registered practitioners can request blood components and
products
8.1.2
Request forms must contain the 4 identity markers as per Trust policy and include
date and time blood/components are required, contact number, name and
signature of requesting clinician and the reason for transfusion - the request will be
refused if the form is not completed appropriately
8.1.3
The request form should clearly state any special blood requirements e.g. CMV
negative or irradiated blood.
8.1.4
For patients who cannot supply the relevant information, the name and date of
birth can be verified by the patient’s family, carer, guardian or other representative
8.1.5
Requests for blood / components will not be processed if the sample is
inappropriately or inadequately labelled as per Trust Policy (4 points of ID, dated,
timed and signed). Samples where the PID has been altered or amended are also
unacceptable
8.1.6
Unidentified/unconscious patients invariably occur in the ED. In these
circumstances a request form must contain and sample labelled with: identity
status, gender and ED number e.g. Unknown / Male / ED number
8.1.7
For non-urgent requests, the laboratory usually requires 48 hours notice to prepare
red cells and blood components/products, to ensure availability. If required sooner
than 48 hours, please ring Bloodbank on Ext 6539 to discuss
8.1.8
Where antibodies are identified, selection of blood may take longer as difficult
cross-matches may require referral to NHSBT at Bristol for testing and sourcing of
antigen negative blood from other NHSBT sites
8.1.9
Requests for blood products/components e.g. platelets and F.F.P. must be made
by direct personal or telephone contact with a member of the laboratory staff
(6539)
8.1.10 Any verbal request must be followed up by written confirmation; this is a legal
requirement to ensure accurate recording and audit
8.1.11 If these products are to be used in emergency situations this needs to be
highlighted to staff in blood bank as a priority
8.1.12 Indication Codes for Transfusion:
http://www.transfusionguidelines.org.uk/docs/pdfs/nbtc_bbt_indication_codes_201
1_10.pdf
8.2 Requests for elective surgery
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8.2.1
Routine surgery group and antibody screen samples will not be processed out side
of normal working hours and it is not possible to make cross-matched blood
components available overnight for early morning theatre cases
8.2.2
Routine surgery should not be cancelled because of non-availability of a group and
antibody screen: suitable units will be made available in the event of an
emergency
8.2.3
Patients who are for an elective procedure must have a blood group antibody
screen performed at least 48 hours before the surgery
9.1 Sampling Blood
10.1
9.1.1
Only suitably trained and competent medical, nursing, midwife or phlebotomy staff
may take blood samples for cross-matching
9.1.2
All blood must be taken in accordance with Trust policy
9.1.3
NPSA regulations require anyone who takes blood samples for cross matching
must repeat competency training every 3 years. They must use an aseptic
technique and label at the side of the patient
9.1.4
See Right patient, right blood - NPSA
9.1.5
For Trust policy see http://www.porthosp.nhs.uk/ClinicalPolicies/Phlebotomy%20and%20venous%20blood%20sampling%20Policy.doc
9.1.6
Samples must be taken using a vacutainer system wherever possible – the use of
needles and syringes can result in abnormal results
9.1.7
The sample must be taken into an EDTA (Anticoagulated) tube and immediately
labelled at the side of the patient by the person who took the sample. The label
must contain the 4 identity markers: surname; given name; date of birth; Identity
Number (e.g. Hospital number, NHS number, ED number if in the Emergency
Department, district number) together with the location. Sample must be signed
and include the date and time taken
9.1.8
Pre-labelled tubes and addressographs must not be used
9.1.9
If ICE requesting is used, suitably trained phlebotomy staff may produce labels at
the bedside after scanning the identity band and carrying out normal patient
identity checks
Collection from a storage fridge
10.1.1 It is a statutory obligation that all staff collecting blood, components or products
must have annual update training and their identity badge validated
10.1.2 Before collecting these from the blood bank, staff must check that a prescription
has been correctly and fully completed. To ensure that all products are properly
requested and prescribed and that the patient details are correct, the prescription
must include:



Completed patient identifiers
The type of blood component to be transfused, plus any special requirements
(e.g. CMV negative)
The quantity to be given
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

The duration or rate of infusion
Date/Time to be given
Only suitably trained, competent and validated staff can collect components/products.
The member of staff should:
10.1.3 Check the patient details on the identity band and patient notes/prescription are
correct
10.1.4 Ensure there is a suitable, patent cannula for the transfusion – Flush the line prior
to collecting
10.1.5 Ensure your patient is ready and consented to having the transfusion. Allow time
to discuss and alleviate any anxieties
10.1.6 Take written confirmation of the patient’s identity to the Blood Bank collection
point. This must contain the 4 points of patient ID (Surname, first name, date of
birth and unique identification number) which matches the patient identity band
10.1.7 Swipe their validated ID card to gain access to the blood bank. Note: it is a
disciplinary offence to use someone else’s card
10.1.8 Select the unit(s) required and confirm the details on the component/product
compatibility label with the written confirmation of the patient’s identity
10.1.9 Use the Electronic release system to scan the bar codes of the unit(s) removed
Note: Scanning instructions for are on the Blood Bank door and on the screen
10.1.10 Take the unit(s) directly to the area in which it is needed and make no
diversions. Blood components and products must not be stored in a ward fridge
10.1.11 Only one unit should be removed at a time, other than in exceptional
circumstances, when a cold box will be issued by Blood Transfusion staff - this
can store blood for up to one hour, after which it should be returned to the Blood
Bank whether the blood is used or not
10.1.12
Start transfusion on return to the clinical area, do not leave to warm up
10.1.13 Any components not started within 20 minutes must be returned to the
bloodbank
10.1
Process for administering blood products/components
Note: for the administration and clinical indication of blood to neonates, please see Appendix 3
and 4
10.1.1.1
Transfusions must be given in clinical areas, where frequent visual and
verbal contact can be maintained
10.1.1.2
Blood components can be administered peripherally or centrally.
10.1.1.3
Nothing must be added to the units under any circumstances
10.1.1.4
The correct giving set must be used for the appropriate blood
component/product and its availability must be confirmed prior to collecting
blood from the Blood Bank.
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Type of Product
Red Cells*
Platelets*
Fresh Frozen Plasma* (FFP)
Cryoprecipitate*
Albumin*
Type of set
Blood giving set with integral filter
Blood giving set with integral filter
Fluid giving set: no need to filter
Fluid giving set: no need to filter
Fluid giving set: no need to filter
Change Set after
12 hours or 4 units of blood
After each unit
At the end of the administration
At the end of the administration
At the end of the administration
*Fresh giving sets should be used with each different component, do not use the same set for
different components as clotting may occur
10.1.1.1
Preparation of the appropriate giving set will prevent any unnecessary
delay in starting the transfusion
10.1.1.2
Packed Red Cells: should be started within 30 minutes of removal from
blood bank and administered within a maximum of 4 hours. Two hours is
suitable for most patients, as slow infusion encourages bacterial growth in
the unit. However, those patients with underlying cardiac or respiratory
conditions may require the transfusion to be given over a longer period of
time to prevent overload
BE AWARE OF THE VOLUME YOU ARE GIVING!
10.1.1.3
Platelets: start immediately once received into area and administers
over 30 minutes. Do NOT refrigerate
10.1.1.4
FFP/Cryoprecipitate:
administer stat
start
immediately
received
into
area
and
10.1.1.5
The same giving set that is used for the transfusion must not
subsequently be used to administer fluids as this will cause waste from
blood components to be administered to the patient
10.1.1.6
A ‘Y connector must not be used, when using a peripheral or central
cannula/line
10.1.1.7
Volumetric pumps can be used with the appropriate administration set
10.1.1.8
No other fluids must be administered at the same time into the same
peripheral cannula. However, if a patient has a double lumen central/PICC
line with distal and proximal ports, separate fluids can be administered
10.1.1.9
To reduce the risk of a transfusion error. Remote checking away from
the patient is unacceptable and unsafe. Positive identification of the patient
at the bedside is essential and MANDATORY
10.1.1.10 It is recommended that only ONE member of staff should check blood
with the conscious patient. Paediatrics and Critical Care have unit
guidance that requires 2 people to check the units, independently, at the
side of the patient - This member of staff must be a suitably trained doctor,
nurse holding current registration of the N.M.C. professional register or ODP
and completed their IV competency
10.1.1.11 The patient’s identity must be confirmed on their identity band and this
must be checked with the information on the component/product label and
the patient’s prescription chart prior to connecting the unit. This must be
done at the patient’s side
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10.1.1.12 If the patient is conscious, they must also be asked to state their first
name, surname and date of birth
10.1.1.13 If the patient is unconscious, or for some other reason cannot
communicate another member of staff or relative/carer can confirm the
patient’s identity
10.1.1.14 In the event of an ‘unknown’ patient, the Identity band, which will
include gender (unknown male/female), emergency number, should be used
for checking purposes
10.1.1.15 The member of staff must check the patient’s identity again and check
the expiry date and time of the blood component/product, before setting up
the transfusion. In the case of any discrepancies, the transfusion must not
be commenced: handwritten amendments are not permitted
10.1.1.16 All patients, including unconscious patients, must have a patient
identification band. This must include: surname, first name, date of birth,
unique identification number as minimum patient identification, (or as
revised by Trust Identity Policy) - NO Identity Band - NO transfusion!
Any discrepancies- do not transfuse and contact bloodbank. Return the unit immediately
11.1
The Transfusion
Conscious patients
11.2
Record the patient’s temperature, pulse, respirations and blood pressure prior to
starting the transfusion
11.3
Ask the patient to report if they are feeling unwell in any way
11.4
Record the patient’s temperature, pulse, respirations and blood pressure within 15
minutes: this is the crucial time, as severe reactions most frequently occur within the first
15 minutes
11.5
Observe the patient regularly throughout the transfusion.
11.6
The recording of further observations and the regularity of those recordings is at the
discretion of the clinical area and is dependent on the clinical stability / condition of the
patient. Very often the recording of further observations is only necessary if the patient
becomes unwell or shows signs of reaction.
11.7
At the end of the transfusion, repeat and record the patient’s temperature, pulse,
respirations and blood pressure
11.8
Visual observations of skin condition, cannula site and urine output must also be
undertaken regularly; and recorded
Unconscious patients
In addition to the observations for a conscious patient:
11.9
Repeat the observations every 15 minutes for the first hour and hourly thereafter
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11.1
Transfusing at Night
11.1.1 Transfusions should not be given at night – between 22:00 and 08:00 – unless the
patient is actively bleeding or has some other urgent clinical need, as deemed by
the doctor/nurse responsible for the patient
11.1.2 Patients who are asymptomatic e.g. from their anaemia, will benefit more from
undisturbed sleep.
Documentation (All patients)
11.1.3 The patient’s notes should contain the reason for transfusion, consent, amount
given, component type and any adverse effects
11.1.4 A follow up entry in the notes should be made to record the clinical response and
whether the transfusion was effective
11.1.5 Good documentation for transfusion is required by Law and is essential for audit
purposes and adverse event investigation
Management of Adverse Reactions – See Appendix 6
Patients with a severe reaction can deteriorate very quickly with hypotension,
respiratory distress, collapse and possible death
If any of these signs occur stop the transfusion immediately
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Patient in distress
Loin pain
Back ache
Fever and / or rigors
Shortness of breath
Urticaria
Flushing
Headaches
Rash
Pain at or near transfusion site
Haemoglobinuria / Haematuria
In children and neonates the following may be seen:
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Dyspnoea
Pyrexia
Restlessness / altered behaviour
Rash
Haematuria
11.1.6 Careful observation of the patient is needed in case any signs or symptoms of an
adverse reaction occur, particularly during the first 15 minutes of the transfusion
commencing. Patients with a severe reaction can deteriorate very quickly with
hypotension, respiratory distress, collapse and possible death.
11.1.7 Mild transfusion reactions, such as mild rise in temperature or rashes, can be
treated by slowing the transfusion and giving paracetamol or antihistamine,
however these still need to be reported
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11.1.8 Moderate or severe transfusion reactions must be stopped, pending a medical
assessment i.e. the patient develops new signs or symptoms or there is a
significant change in their observations. The patient’s vital signs must be recorded
and a check made to ensure venous and arterial access is patent.
11.1.9 SHOT recommends that TACO (Transfusion Associated Circulatory Overload)
and TRALI (Transfusion Related Acute Lung Injury) are being under-reported. Any
suspicion of either transfusion related incident, please contact the Transfusion
Practitioner during working hours (Monday – Friday 09:00hrs to 15:00hrs) and the
on-call Haematologist via the Trust Switchboard. (See appendix 6)
11.2
Documentation of Incidents/Reactions
11.2.1 All incidents must be documented via the Trusts DATIX system
11.2.2 Transfusion related incidents are copied via DATIX to the Hospital Transfusion
Practitioner who, in conjunction with the Blood Bank Manager, will ensure follow
up and any actions taken.
11.2.3 Any “wrong blood component in wrong patient” or other major incident must be
recorded as a SIRI and fully investigated in accordance with the Trust Policy
11.2.4 The transfusion unit, attached giving set and any previous unit bags that have
been used in this episode, must be sent to the Blood Bank immediately
11.2.5 All adverse reactions must be documented as fully as possible on an Adverse
Reaction Form available from the Blood Bank and the form returned to the
Hospital Transfusion Practitioner immediately
11.2.6 All incidents must be fully documented in the patient’s notes
11.2.7 SHOT/SABRE reporting will be undertaken by the Hospital Transfusion
Practitioner and follow up and actions documented and reports made available on
request
11.2.8 All adverse incidents and reactions will be discussed by the Hospital Transfusion
Team and reported to the Hospital Transfusion Committee
11.3
**Appendix 1 gives full details of the management of adverse reactions in adults and
Appendix 2, full details of the management for children.
11.4
Rapid Infusion and Blood Warmers
11.4.1 The routine warming of blood is not necessary
11.4.2 Blood warmers increase the risk of bacterial growth, so should not be used
routinely, except in the following circumstances:




Major Haemorrhage where level 1 infusers are used
Infants requiring exchange transfusions
Patients who have clinically significant cold agglutinin antibodies
Patients who are hypothermic or at risk of becoming hypothermic due to complicated or
prolonged surgery
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11.4.3 If blood warming is required, this must only be done using a specifically designed
commercial device, with a visible thermometer and audible alarm that ensures the
blood is not warmed over 410C.
11.4.4 The device must be monitored and validated every 12 months as blood warmers
are extremely dangerous if they malfunction
11.5
Storage
11.5.1 Blood is to be stored only in a purpose built, fully validated, alarmed blood bank at
between 2 – 8 0C to prevent the risk of bacterial growth. Note: the alarm is
connected to the switchboard to alert to any malfunction.
11.5.2 Blood must NEVER be stored in a ward fridge, as the temperatures in these
fridges are not suitable for blood storage
11.5.3 Cross-matched blood units are stored for 48 hours in the issue fridge, after which
time they are taken back to the laboratory for re-use on other patients, unused
units must be returned to the bloodbank
11.5.4 Platelets and fresh frozen plasma (FFP) and Cryoprecipitate must not be
refrigerated but transfused as soon as possible to ensure products are at optimum
quality, unused units must be returned to the bloodbank
11.6
Transportation to other sites
11.6.1 Only staff who have
component/products
received
GMP
training
may
transport
blood
11.6.2 Blood components/products must only be transported between sites in a validated
and sealed cold box designated for this purpose
11.6.3 The person packing the product/component must record the time and date it was
placed into the box and the time for which storage would be satisfactory or the
time the product must be returned to blood bank
11.6.4 On receipt of the cold box, a suitably trained and competent member of staff must
sign to acknowledge appropriate maintenance of cold chain and time of arrival
and faxed back to the Bloodbank. Note: Any discrepancies must be notified
immediately to the sending bloodbank, on no account must this blood be used without
seeking further advice
11.6.5 Confirmation of receipt of correct product must be returned to the laboratory: using
Blood Bank SOP 305 (Appendix 5). This is to comply with the Blood and Safety
Quality Regulations and to ensure the provision of a validated “cold
chain“protocol.
11.7
Major Incidents
11.7.1 In the event of a Major Incident, Bloodbank will follow the Pathology Major
Incident Plan
11.8
Major Haemorrhage
11.8.1 In the event of a Major Haemorrhage, please contact bloodbank on ext: 6539 to
alert staff to the event. The Trusts Major Haemorrhage policy will be followed
11.8.2 In the event of a Major Obstetric bleed, initiate the ‘red box’ system
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12 TRAINING

Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in
the Training Needs Analysis. It is included in mandatory Corporate Induction and in Essential
Updates

Staff attend classroom delivered Essential Update training every three years and undertake
refresher training via the Electronic Staff Record (ESR) system in the intervening years

All training is recorded on the (ESR) from which the Learning and Development Team provide
a monthly heat map to each Clinical Service Centre (CSC), to enable monitoring of
compliance

Compliance is further monitored through the CSC performance reviews with the Executive
Team

There is an approved Trust Competency for preparing and administration of blood
components (Transfusion Competency) every 3 years, Collection and Transportation
Competency, Annually. Staff must be assessed by a Level 3 Assessor and this applies to all
staff that collect, transport and administer a blood component/product to a patient

There are also approved trust competencies for:
o
o
o
o

Phlebotomy and Venous Blood Sampling (Adults)
Phlebotomy, Heel Pricks and Arterial Blood Sampling in Neonates
Post Operative Reinfusion of Shed Blood - Theatres and Recovery
Post-operative reinfusion of patient’s own shed blood – Ward/Clinical Area
Renal Unit appendix
o http://pht/Departments/renaltransplantation/Specialty%20Guidelines%20and%20Policies/Form
s/AllItems.aspx
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8. REFERENCES AND ASSOCIATED DOCUMENTATION
External
The Blood Safety and Quality Regulations 2005 SI 2005/50. London: The Stationery Office.
www.opsi.gov.uk
Better Blood Transfusion – Appropriate Use of Blood. London. Department of Health
www.dh.gov.uk
UK Blood Safety and Quality Regulations 2005. Implementation of the EU Blood Safety
Directive: Background and Guidance on reporting Serious Adverse Events & Serious Adverse
Reactions. London. MHRA www.mhra.gov.uk
SABRE – A User Guide: UK Blood Safety and Quality Regulations 2005 – Implementation of
the EU Blood Safety Directive. London. MHRA www.mhra.gov.uk
Patient Briefing: Right Patient, Right Blood. London. NPSA www.npsa.nhs.uk
Implementation of Competencies for Blood Transfusions. London NPSA. www.npsa.nhs.uk
Serious Hazards of Transfusion Annual Reports. 2011. www.shot-uk.org
Transfusion guidelines for neonates and older children 2004 and 2007 amendment to the
transfusion guidelines for neonates and older children (specification of imported FFP)
http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.html?dpage=1&dtype=Tran
sfusion&sspage=0&ipage=0#gl
The clinical use of red cell transfusion 2001
http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.html?dpage=1&dtype=Tran
sfusion&sspage=0&ipage=0#gl
Guidelines on the use of irradiated blood components 2010
http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.html?dpage=0&dtype=Tran
sfusion&sspage=0&ipage=0#gl
Handbook of Transfusion Medicine (2007), D.B.L. McClelland, Fourth Edition. The Stationary
Office Norwich.
Indication Codes for transfusion:
http://www.transfusionguidelines.org.uk/docs/pdfs/nbtc_bbt_indication_codes_2011_10.pdf
Internal
Policy for the Management of Adverse Incidents and Near Misses
Policy for the Management of Serious Incidents Requiring Investigation
Refusal of Blood Components Guidelines
Trust Transfusion Guidelines
EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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MONITORING COMPLIANCE
As a minimum the following elements will be monitored, to ensure compliance
Minimum requirement to
be monitored
Lead
100% of requests for
blood samples for pretransfusion compatibility
are made, taken and
labelled appropriately
Phlebotomy
Clinical
Educator
Process for the
administration of all
transfusions, including
patient identification
100% of patients receiving
a transfusion have
appropriate care
Hospital
Transfusion
Practitioner
100% staff involved in the
transfusion process are
competent
Transfusion laboratory
retains its CPA (UK) Ltd
Hospital
Transfusion
Practitioner
Transfusion
Laboratory
Manager
Transfusion
Laboratory
Manager
Pathology
Manager
Transfusion retains its
MHRA compliance
Transfusion meets all
CQC requirements
Hospital
Transfusion
Practitioner
Tool
Audit against a
modified
standards from
Phlebotomy and
Venous Blood
Sampling Policy
Identity Band /
Patient
Identification Audit
Frequency of
Report of
Compliance
Annually
Reporting arrangements
Lead(s) for acting on
recommendations
Policy audit report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
Every 2 years
Policy audit report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
Review of all
adverse
transfusion
reactions
Review of
competencies
Annually
Policy audit report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
Annually
Policy audit report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
CPA compliance
and inspection
Internal inspection
against standards Annually
Annually
Policy audit report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
Report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
Annually
Report to:
Hospital Transfusion Committee
Chair of Hospital
Transfusion Committee
MHRA compliance
and inspection
CQC compliance
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Blood Transfusion Policy. Issue 6. 12.03.2010 (Review date: December 2012)
05/02/2016
Page 20 of 32
Appendix 3
ADMINISTRATION: NEONATES AND OLDER CHILDREN
1. Parental Information
1.1 Parents should:





Be informed of the reason for the transfusion
Be involved in a discussion about the risks and benefits
Be informed of any other options
Be offered information leaflets
Consent to the transfusion, if it goes ahead (Note: it is appropriate to discuss with
parents and document in patient notes)
Routine checks before administration
2.1 The following checks should be undertaken






The details on the unit of blood, printed labels and baby/child’s identity bands must all
match; to ensure the right blood component type is given to the right baby or child
If, for any reason, the parent or child cannot confirm identity, two staff should do so by
the bedside
The blood group and Rhesus group are compatible with those of the patient
The unit ‘use before’ date is current
Should any of the above checks highlight a discrepancy, the blood component(s) must
not be used and returned to the blood bank immediately
If cover with paracetamol and/ Chlorphenamine is prescribed and administer in a timely
manner.
Types of components for transfusion
For neonates and patients under 1 year of age, CMV negative units are recommended.
Some other groups of children may also require CMV negative blood products, e.g. a patient
who had an allogeneic Stem Cell Transplant. This should be prescribed on the IV chart.
In an emergency situation then the clinical needs of the patient may require transfusion with the
‘Next Best Product’ and it may not be necessary to obtain CMV negative products for example.
Some babies / children are severely immuno-compromised and require irradiated blood. This
will be indicated on the label and on the front of the baby / child’s notes and the request form
4. Procedure for low volume blood transfusion
 Wearing gloves, connect blood-giving set to the blood bag with the 3- way tap closed to
the filter – this keeps the blood free from contamination
 Connect 50ml syringe to the 3-way tap
 Connect extension set to the remaining 3-way tap port
 Open 3-way tap to syringe and blood filter only
 Withdraw required amount of blood plus an extra 2mls for priming of infusion lines and
‘dead spaces’. This will ensure the baby is not inadvertently given too much fluid
 Purge air bubbles in syringe back into blood bag
 Open 3-way tap to extension tubing and purge blood through the extension set line
 Take the transfusion to the baby/child, complete with blood bag, filter and syringe
5. Administration of blood transfusion
 Check the baby/child’s identify against both name labels: wrists and ankles and the
compatibility label on the blood
 Flush the cannula with Sodium Chloride 0.9%
 Only connect the blood once these checks are satisfactory,
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
Two nurses must check the pump has been set at the correct rate and volume limit and
that the 3-way tap is open to the baby/child (where syringe driver used), not the blood
bag
6. Observations
 Document baseline observations of temperature, pulse, respirations and blood pressure
prior to start of transfusion
 Continually monitor the apex and respiratory rate during the transfusion, so any adverse
reactions can be detected
 Check and record temperature, pulse, respirations and blood pressure at 15 minutes,
30 minutes and 60 minutes then hourly until completion. Note: severe reactions most
frequently occur within the first 15 minutes of each transfusion.
 For Neonates record baseline observations, at 15mins and end of transfusion.
Intensive Care patients are continuously monitored.
 Have the intravenous site easily visible
 For neonates only, record neonatal intravenous extravasation score (NESS) hourly on
IV chart
7. Feeding during transfusion (neonates)
7. 1. Routine stopping of feeds is not necessary but stopping or reducing feeds should be
considered for babies in intensive care to protect baby from fluid overload with any of the
following:




History of poor feed tolerance or abdominal distension
History of Inter Uterine Growth Retardation - IUGR (Less than 9th centile)
History of poor Doppler’s / absent/reduced end diastolic flow
Recent changes in feeds e.g. addition of fortifier
7.2 Babies in special care with
 History of poor feed tolerance
 History of suspected necrotizing entero-colitis (NEC)
Note: If feeds have been reduced or stopped check blood sugar half way through the
transfusion: to ensure vulnerable babies do not suffer from low blood sugar
Furosemide
8.1 Furosemide is not needed routinely for top-up transfusions but it should be considered for:
 Oxygen dependent babies with chronic lung disease
 Oedematous babies
8.2 If Furosemide has been prescribed
 Set the volume limit for half the total volume – to ensure the baby does not become fluid
overloaded and adequate checks are made during the infusion
 Once administered, reset the volume limit for the remainder of the transfusion
9. When the transfusion is complete
 Flush the cannula with Sodium Chloride 0.9%
 Disconnect the blood giving set from the pump
 Dispose of the unit/s and the giving set in the yellow clinical waste bags
 Complete the middle section of the compatibility label and return it to the blood bank as
soon as possible
 Check the haemoglobin level 24 hours later
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9. Documentation – Paediactrics and Neonates
The following should be documented:
 The blood availability record (red card) should be secured in patient notes
 The reason for the transfusion should be documented prior to requesting
component/product
 The amount and type of blood given
 Any adverse effects
 Completion of the blood compatibility labels. Two registered practitioners must sign in
the appropriate place and affix to the current continuation sheet in the patient notes
(returning the third section to blood bank)
 The clinical response and whether the transfusion was effective should be recorded.
 Any relevant parent information leaflets given
 Documentation for all products/components is on the pink Record of Blood Component/Products
Chart, which is kept in the pts notes. Blood labels are put on this chart also.
CLINICAL INDICATION FOR THE ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS
– NEONATES ONLY







Symptoms of anaemia
Tachypnoea
Tachycardia
Recurrent apnoea
Oxygen requirement
Poor feeding
Failure to gain weight
Transfusion triggers
Given to ventilated ill neonates requiring oxygen to keep haemoglobin levels more than 12 g/dl
CPAP in oxygen to keep Hb. more than 12 g/dl, CPAP in air to keep Hb more than 10 g/dl
Nasal prong oxygen to keep Hb. more than10 g/dl
In air, poor feeding and growth, reticulocytes less than 4.0% to keep Hb more than 8 g/dl
In air, feeding and growing, reticulocytes less than 4.0% to keep Hb more than7 g/dl
Calculation for Top-Up Transfusion
To ensure adequate volume to reduce the need for repeat transfusions and hence multiple
donor exposure
Packed cells – (desired Hb – actual Hb) x wt in kg X 4.
Or; 10 – 15mls/kg of packed cells.
Usage
Blood should be used within 30 minutes of removal from fridge
Transfusion should be completed within a maximum of 4 hours
Aim for the shortest time possible for infusion – look at the amount in mls being prescribed
Platelet Transfusion Triggers
Platelets are prescribed for very pre-term infants with sepsis or disseminated intravascular
coagulopathy (DIC)
Platelet dose is 10 ml/kg
Usage
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Platelets are stored at room temperature and should be kept agitated to prevent clumping.
Platelets should be infused within 1 hour of arrival on the Neonatal Intensive Care Unit
Platelets are withdrawn for bag using a mini-spike and are filtered before use.
Transfusion should be administered over 30 - 60 minutes
EXCHANGE TRANSFUSION EQUIPMENT LIST
(Equipment is kept in Ventilation Cupboard)





Blood Warmer
Graesby 500 Pump.
Equipment to Continuous monitor HR, O2 Saturation, Blood Pressure &Central and peripheral
temperature
Basic Resuscitation Equipment
Bedside glucose analyser
Exchange Transfusion bag (kept with above equipment)







Blood Warming Coil (Astotube)
Graseby blood giving set –(Reference Filter No591.082K).
Volume Exchange In And Out Chart (can be printed from Intranet, Departments, NICU, NICU
charts, Filing Cabinet)
Basic dressing pack
Various syringes – 2ml to 20ml
0.9% saline vials
Green needles + Filter needles
You will also need:




Chlorhexidine – Strength dependant upon the gestation
Sterile Gloves
Emergency Resuscitation box – nearby
Blood bottles – B. Culture x 2
 Red top x 2
 Pink/mauve x 2
 Yellow top TBS x 2

2 x blue clotting bottles from TPN fridge. Keep cold until use.
If UAC/UVC required use pre packed bag from clean utility
EXCHANGE TRANSFUSION - NURSING GUIDELINES

The baby should be NBM for as long as possible prior to the procedure, and should remain NBM
for at least 24hrs post procedure.

Try to keep phototherapy going at all times if possible. During the procedure you may have to turn
the phototherapy lights off frequently, to check the baby’s colour and transfusion sites - remember
to watch the colour of the digits distal to any peripheral arterial line.

If the baby is unstable at any time during the procedure, keep the phototherapy lights switched off
to enable closer observation.

If the baby can maintain its temp, it is easier to perform the exchange with the baby in the open
Draeger. If an incubator is used the procedure should be performed through the portholes if at all
possible.
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Setting up for transfusion


Collect all equipmentAttach Equipment to Continuously monitor: HR, O2 Saturation, Blood Pressure &Central and
peripheral temperature
Ensure resus equipment is available and ready to use i.e.:  suction + catheters
 Bag and Mask 02
 Face mask
 Emergency drug box

If lines need siting, discuss with medical staff re the estimated time that this will take, before
planning when to remove the blood from the blood fridge. If several units of blood are to be used,
you may want to leave one unit until nearer the time that this will be required. But you will have to
have a runner available to collect the blood, and another person available to check it prior to you
needing it. You will be too busy documenting volumes to do this!

Assist the medical staff with any lines that need siting. Exchange via a peripheral arterial and
large venous line is the method preferred by the Consultants, but a UAC and UVC can be used,
or any combination of the above. Remember that UACs/UVCs need X-ray conformation prior to
use.
When ready, check the blood, as for blood transfusion.. Blood should be Rhesus neg., CMV
neg., group compatible, and fresh, (<5 days old). It should be irradiated.
Rate of Infusion and Total Volume of Infusion

The blood infused every 5 mins should = volume of blood removed every 5 mins.
For babies<l kg. = 5mls. In 5mins.= 60mls/hr.
1-3kgs. = 10mls. in 5 mins. = 120mls/hr
>3kgs. = 20mls. in 5 mins. = 240mls/hr.
Confirm with the medical staff how much they plan to remove every 5 mins. This will need to be
set as an hourly rate on the Graesby 500 pump

NB. The first few aliquots in and out, may be performed at half volume, in order to ensure that the
procedure is tolerated. If this is to be the case, then you will need to half the infusion rate during
this time.

Total volume infused is usually equal to twice the babies blood volume, which
= 70mls/kg. Check out the total volume to be exchanged, by asking the medical
staff.
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APPENDIX 4
TRANSPORT OF BLOOD AND BLOOD COMPONENTS TO OTHER SITES
Introduction
This procedure must be followed, to ensure that there is a complete audit trail for blood
components to be transfused at hospitals other than QAH. The procedure satisfies the “cold
chain“ requirements as laid down in the Blood Safety and Quality regulations (50) 2005.
This covers the full process from provision of compatible blood components to the final fate and
documentation of every product.
The following hospitals / care centres are routinely served:

Petersfield Hospital*

Rowans Hospice

Spire Portsmouth Hospital (ex BUPA) Havant

Gosport War Memorial Hospital*

St.Mary’s Hospital

ISTC – Portsmouth*
* These hospitals have suitably validated blood storage fridges
Transport procedure
Commencement







Contact the Senior Nurse at the intended destination to confirm that blood components
are ready for dispatch. State the patient’s details and the amount and type of product to
be dispatched
Sign the compatibility labels
Organise suitable transport
Place the blood components in a validated transport box with sufficient cool packs to fill
any ‘dead space’
Fill in the “Blood in Transit Form” clearly stating the destination, date and time packed,
expiry time and person who packed the box
Label the box – “URGENT BLOOD FOR (NAMED) HOSPITAL”
Seal the box
On arrival




Inspect seal and reject if broken, confirm with documentation that cold chain has been
maintained correctly. Any deviations contact bloodbank immediately
On arrival at destination the box MUST be unpacked and the units placed in to the
designated blood fridge. In the absence of a designated blood fridge, the product can be
stored in the insulated box for an absolute maximum of 4 hours from packing
Transfused blood - All units that are transfused MUST have the middle part of the
compatibility label completed and returned to the issuing blood bank as soon as
possible
Unused blood - Any used blood MUST be returned to the issuing blood bank in a sealed
transport box as above
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Appendix 5 - Renal Transfusions
Administration: Adults on Haemodialysis/Haemofiltration.
Patients:
 Requiring transfusion of Packed Red Cells who have Acute Kidney Injury, Chronic Kidney Disease or
Established Kidney Failure.
 Require Haemodialysis/Haemodiafiltration therapy.
 Requiring the transfusion of Packed Red Cells which is planned and non emergency.
Routine Checks before Administration:
 The following checks should be undertaken
 The details on the patient’s identification band and prescription chart match exactly
 The patient’s blood group can be confirmed with the patient details on apex.
 If for any reason the patient cannot confirm identity, two nurses should do so by the patient’s bedside.
 The Packed Cells unit ‘use before’ date is current.
 Should any of the above checks highlight a discrepancy, the Packed Cells unit should not be used and
returned to the Blood Bank immediately.
 The patient is in an observable bed/dialysis station to allow close monitoring during transfusion.
Observations
 For Isle of Wight Renal Care Centre refer to local Policy
 Document the patient’s baseline observations, temperature, pulse, blood pressure and respirations
prior to the start of Haemodialysis/Haemodiafiltration.
 Baseline observations should be recorded and documented 15 minutes after the start of transfusing
the first unit, and each subsequent unit.
 Standard Monitoring and documentation required of the patient on Haemodialysis/Haemodiafiltration
should continue in addition to the transfusion observations.
Administration of Blood Transfusion:
 For Isle of Wight Renal Care Centre refer to local policy
 The Registered Nurse should check the patient’s identity with the Patient to confirm their details
against their identification band, the Prescription Chart and the unit of Packed Cells. If the patient is
unable to confirm their details then two nurses should check the details of the patient with the Packed
Cells to be administered.
 The fluid volume of the total number of units to be transfused during the
Haemodialysis/Haemodiafiltration session is to be added to the fluid loss removal prescription unless
otherwise instructed by the medical team. The total volume should be checked by two nurses.
 The Unit of Packed Cells should be administered using a volumetric pump and appropriate infusion set.
 The infusion set should be connected to a port on the ‘arterial’ line of the dialysis circuit before the
dialysis filter. This is to allow for the clearance of potassium within the unit of Packed Cells.
 A maximum of three units can be administered within a 4 hour Haemodialysis/Haemodialfiltration
session. Each unit should be infused over a minimum of one hour and should take no more than 2
hours to transfuse due to the possibility of bacterial growth. If possible the transfusion should be
completed 30 minutes prior to the end of the Haemodialysis/Haemodiafiltration session to allow for
fluid and potassium clearance.
 One unit of Packed Cells should be removed from the Blood Fridge at a time. This is in the event of
further units not being used.
When the Transfusion is Complete
 Keep the empty unit and used line connected to the Haemodialysis/Haemodiafiltration circuit until the
treatment session is complete.
 Dispose of the unit and lines with the Haemodialysis/Haemofiltration lines in the appropriate clinical
waste bin or durable yellow clinical waste bag.
 Complete the middle section of the compatibility label and return it to the Blood Bank as soon as
possible.
 Check the patient’s haemoglobin level the next day if they are an inpatient or on their next
Haemodialysis/Haemofiltration session if they are an outpatient.
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Transfusion on Haemodialysis/Haemofiltration without anti-coagulant
 For Isle of Wight Renal Care Centre refer to local policy
 The Registered Nurse should check the patient’s identity with the patient to confirm their details
against their identification band, the Prescription Chart and the unit of Packed Cells. If the patient is
unable to confirm their details then two nurses should check the details of the patient with the Packed
Cells to be administered.
 The fluid volume of the total number of units to be transfused during the
Haemodialysis/Haemodiafiltration session is to be added to the fluid loss removal prescription unless
otherwise instructed by the medical team. The total volume should be checked by two nurses.
 The Unit of Packed Cells should be administered using a volumetric pump and appropriate infusion set.
 As patient condition allows the Packed Cells should be transfused through a peripheral cannula or a
third access port on their central access. This is to minimize the risk of clotting in the dialysis filter. If
access cannot be established then the Packed Cells can be transfused through a port on the ‘arterial’
line. A maximum of three units can be administered within a 4 hour Haemodialysis/Haemodialfiltration
session. A unit should take no more than 2 hours to transfuse.
 If possible the transfusion should be completed 30 minutes prior to the end of the
Haemodialysis/Haemodiafiltration session to allow for fluid and potassium clearance.
 The Haemodialysis/Haemodiafiltration circuit should be flushed with sodium Chloride 0.9% as stated in
the Standard Operating Procedure for Heparin Free Haemodialysis/Haemodiafiltration within the
Wessex Renal & Transplant Service.
When the Transfusion is Complete
 Disconnect the empty unit and used line and dispose of in a Clinical Waste bin or Clinical Waste
durable bag.
 If the unit is transfused via the Haemodialysis/Haemodiafiltration circuit keep the empty unit and used
line connected until the treatment session is complete. Then dispose of the unit and line with the
Haemodialysis/Haemofiltration lines in appropriate clinical waste bin or Clinical Waste durable bag.
 Flush the peripheral cannula or central access port with Sodium Chloride 0.9%.
 Complete the middle section of the compatibility label and return it to the blood bank as soon as
possible.
 Check the patients’ haemoglobin level the next day if they are an inpatient, or on their next
Haemodialysis/Haemofiltration session if they are an outpatient.
In Case of Transfusion Reaction:
 As per Blood Transfusion Policy. If the Medical team advises discontinue
Haemodialysis/Haemodiafiltration and document in the Medical and Nursing Notes.
 All Transfusion Incidents must be reported on a Trust Adverse Incident Reporting (AIR) Form.
Documentation
The following should be documented:
 Completion of the blood compatibility labels. The Registered Practitioner must sign in the appropriate
place and affix to the current continuation sheet in the patient notes (returning the third section to
blood bank).
 The transfusion should be prescribed on an infusion chart and each unit signed and dated by the nurse
setting up the infusion. This is to be kept in the patients notes.
 The reason for the transfusion should be documented prior to requesting the Packed Cells.
 Document patient consent to treatment, include risks and benefits
 The transfusion should be prescribed on the Haemodialysis/Haemofiltration prescription chart.
 Any adverse effects.
 The transfusion is recorded on the PROTON record for that patient.
Training Requirements
 Annual updates are mandatory for all staff groups who handle blood products. It is essential that the elearning/MOT is completed yearly and the classroom session on Blood Awareness is attended at 3
yearly intervals.
 Completion of the Trust Generic Competency: Administration of Blood Products, which is assessed by a
Level 3 Assessor every 3 years.
 Achieves Level 1 and 2 of unit 2a of the Renal Staff Development Programme: Care of a Patient on
Haemodialysis.
 Knowledge of the Standard Operating Procedure for, Heparin Free Haemodialysis/Haemofiltration
within the Wessex Renal and Transplant Service.
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Appendix 6
Common Complications Associated with Transfusion of a Blood Component
(Definition of a blood component: Red cells, Platelets, FFP, Cryoprecipitate)
(A)
Problem
Acute Event
Likely Cause
Timing of Event
Severity
Management and Prevention
Intravascular
Haemolysis
Major ABO
incompatibility
Almost Immediately
following start of
transfusion
Potentially
Fatal
10% Mortality
Check for DIC and renal failure
Maintain BP and renal perfusion
Contact: On-call Haematologist, Transfusion Practitioner,
Bloodbank
Initiate RED adverse incident report
TACO
(Transfusion
Associated
Circulatory
Overload)
Rapidly infused, large
volume infusions or
high TACO risk
patients
Occurs usually within 2 - 6
hours of transfusion
Potentially
Fatal
Accurate assessment of patients at risk of TACO
Careful attention to fluid balance
Consider appropriateness of transfusion
Consider rate of transfusion and diuretic cover
Initiate AMBER adverse incident report
TRALI
(Transfusion
Related Acute
Lung Injury)
Leucocyte Antibodies
in donor blood
During or within 6 hours of
transfusion – RARE but
can be confused with
ARDS
Potentially
Fatal
Manage as for ARDS refer to Critical Care Team
Chest X-Ray – shows bilateral pulmonary infiltrates
Initiate AMBER adverse incident report
TAD (Transfusion
Associated
Dyspnoea)
Transfusion of donor
blood and patient comorbidities
Potentially
Fatal
Anaphylaxis
IgA Antibodies in
donor or recipient
Bacterial
Contamination
Anti-leucocyte
Antibodies
Respiratory distress within
24 hours of transfusion
and no other associated
cause
Immediate
Assess respiratory distress
CXR
Oxygen saturations and ABG’s
Initiate adverse incident report, grade appropriately
Maintain ABC’s and follow Anaphylaxis Policy
Initiate adverse incident report, grade appropriately
Manage septicaemia
Initiate adverse incident report, grade appropriately
Treat with Anti-pyretic (e.g. Paracetamol 1g)
Initiate adverse incident report, grade appropriately
Septic Shock
Febrile, Nonhaemolytic
Urticaria
IgE Antibodies in
donor blood
During transfusion
Up to several hours post
transfusion
During transfusion
Potentially
Fatal
Potentially
Fatal
Unpleasant
but not usually
life threatening
Unpleasant
but not usually
life threatening
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Treat or prevent with Antihistamine (Oral or IV)
Initiate adverse incident report, grade appropriately
(B)
Delayed Event
Delayed
haemolytic
reaction
IgG Antibodies to
donor blood
2 – 26 days post
transfusion
Not usually life
threatening
TA-GvHD
(Transfusion
Associated Graft
Versus Host
Disease)
Post Transfusion
Purpura (PTP)
Post Transfusion
Viral Infection
Iron Overload
Donor lymphocytes
Extremely rare up to 30
days following transfusion
Usually fatal
Recipient antibodies
against HPA system
Infected donor blood
5 – 12 days post
transfusion
Post transfusion
Rare but
treatable
Rare
Multi-transfused
patients
Occurs either with single
episode of multi-units or
long term transfusion
therapies
Rare but
treatable if
diagnosed
References:
Annual SHOT report 2011 ISBN 978-0-9558648-4-1
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Poor response to transfusion
Jaundice
Send samples for investigation
Review transfusion needs
None seen in the last 10 years following leucocyte depletion
Irradiated blood to ‘at risk’ groups
Contact Bloodbank to arrange patient investigation at
platelet laboratory
Depends on virus
Seek specialist medical advice
Use iron chelation therapy or venesection
Monitor LFT’s and cardiac enzymes
Consider cardiac scans
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