TRANSFUSION SERVICES (BLOOD BANK)
Introduction
The Christiana Care Health Services maintains a Blood Bank and Transfusion Service. This
section on Transfusion Therapy is designed to inform the Christiana Care Health Services staff
of services provided by the Blood Bank Department and provide guidelines for transfusion. The
"Circular of Information for the Use of Human Blood & Blood Components" and "Blood
Transfusion Therapy -A Physician's Handbook" are available in the Blood Bank and should also
be consulted for additional information.
Indications for Transfusion Therapy
Transfusion therapy with red blood cells (RBCs) is indicated for restoration of oxygen carrying
capacity and correction of anemia. Most patients are not significantly symptomatic until the
hemoglobin level is less than 7-8 grams/dl, however factors such as cause for the anemia and
comorbid illnesses are considered in each transfusion decision. Platelets are indicated for
correction of significant thrombocytopenia with bleeding, for prophylaxis in profound
thrombocytopenia (usually less than 10,000), or for patients with thrombopathies. FFP and
cryoprecipitate may be indicated for correction of coagulation defects in certain circumstances.
All transfusion decisions involve integration of the clinical information and laboratory data and
reflect both the benefit and risks of the therapy.
Definitions and Explanation of Terms
Blood Bank - A laboratory which is responsible for the collection, processing, manufacture,
and storage of human blood and its components.
Transfusion Service - A laboratory which is responsible for testing patient samples, storage
of blood products, and issuing products for transfusion.
Transfusion Therapy - The infusion of blood or one of its components for therapeutic
purposes.
Order - Formal written instructions from a physician which appear on a patient chart or on a
prescription form requesting services and/or products.
Request - The act of asking to supply products or services as a result of the physician's order.
Transfusionist - A physician or registered nurse specially trained in transfusion practices who
performs the phlebotomy and/or starts to transfuse the blood or blood component. Only the
transfusionist may break the seal of the unit.
Transfusion Reaction - Any untoward effect resulting from a transfusion. All suspected
reactions must be reported to the patient's physician and the Transfusion Service Lab (Blood
Bank) and/or IV nurses at the time it is noted.
Unit Label - The non-removable label on the front of the blood or blood component
containing information regarding the contents of that unit.
Requisitions
All Transfusion Service Laboratory (TSL) tests can be ordered by using a manual Transfusion
Service Laboratory Requisition (the red and white form #18821 S) or by the Clinical Care
System (CCS).
All manual requisitions must be stamped with an addressograph plate or the information
normally found on the plate must be legibly handwritten. The physician's order must be
transcribed in the space provided on the requisition for requesting blood and blood components.
Both types of requisitions (manual and CCS) have a space for the signature of the phlebotomist.
Each specimen sent to the Blood Bank must be accompanied by one of the requisitions. The
only exception to this would be immunology tests ordered through the CCS. No testing will be
performed unless the specimen and a properly signed slip have been received and all patient
identification information match.
Services Provided by the Transfusion Service Lab
Diagnostic
Hepatitis Markers - tests for infectivity and/or evidence of prior exposure to the viruses (viral
antibodies)
HBsAg and confirmation - used to detect the presence of the Hepatitis B surface protein in
the serum.
Anti-HBc - detects the antibody to the Hepatitis B core antigen which is present in nearly all
chronic HBsAg carriers.
Anti-HBs - detects the antibody to HBsAg and usually indicates immunity to Hepatitis B
virus.
Anti-HCV - detects the antibody to the Hepatitis C virus previously called non-A, non-B
hepatitis.
Anti-HAV(IgM) - used to detect the IgM class antibody to Hepatitis A that appears during
the acute phase of infection and persists through early convalescence.
Anti-HBc(IgM) - used to detect the IgM class antibody to the Hepatitis B core antigen. It is a
reliable marker for acute disease and can be valuable for diagnosing post-transfusion
Hepatitis B.
Immunologic Tests
Anti-HIV I/II - detects antibodies to human immunodeficiency viruses type 1 and/or type 2
which cause Acquired Immunodeficiency Syndrome (AIDS).
Rapid HIV – detects antibody to HIV 1 only. Limited to needlestick/exposures through
Employee Health and untested mothers in L&D.
Anti-HTLV-I/II - detects antibodies to the human T-lymphotropic virus type I/II which has
been associated with Adult T-cell leukemia.
CMV - semi-quantitative measurement of IgG antibodies to cytomegalovirus in serum to
indicate past or current infection.
Rubella - quantitative measurement of IgG antibodies to the Rubella Virus in serum to aid in
the determination of immune status.
Toxoplasma - quantitative measurement of IgG antibodies to Toxoplasma gondii in serum
to aid in the determination of immune status.
Send Out Tests - tests sent to facilities outside the hospital.
HAV - antibody to Hepatitis A virus. This combination test detects IgM and IgG antibodies.
HDV - antibody to Hepatitis Delta virus.
HBeAg - detects Hepatitis B envelope antigen.
Anti-HBe - antibody to HBeAg
HCV PCR - Hepatitis C by polymerase chain reaction method, qualitative test.
HCV RIBA - Hepatitis C by radio-immunoblot assay
HCV RNA - Hepatitis C ribonucleic acid, quantitative test.
HIV I and HIV II Western Blots - confirmatory test for HIV I and HIV II that detects viral
gene proteins.
HTLV I/II Western Blot - confirmatory test for HTLV I/II
Rubella IgM - measurement of IgM antibody
CMV IgM - measurement of IgM antibody
Toxo IgM - measurement of IgM antibody
Antibody Titer
Titration is a semi-quantitative measurement of the amount of antibody contained in a serum; the
higher the titer, the more antibody present. The serum is diluted serially until the antibody can
no longer be detected and the titer is reported as the reciprocal of the highest reactive dilution.
Both autoantibodies and allo-antibodies may be titered. Cold (auto) agglutinin titer may be
elevated in the serum of patients with certain diseases; for example, an elevated titer (greater
than 32) in a patient with respiratory symptoms may be indicative of mycoplasma infection.
Serial titers of autoantibodies may be employed to assess response to therapy. Allo-antibodies
such as the naturally occurring isoagglutinins anti-A and anti-B are sometimes titered in
assessing immune competence.
Cold antibodies are usually complete (IgM) antibodies with a blood specificity of Anti-I. Titers
less than or equal to 32 are of no significance. In patients with acquired hemolytic anemia
associated with a cold antibody, the titer is usually in the thousands. Elevated cold agglutinin
titers are also seen in primary atypical pneumonia.
The most frequent use of the antibody titer is to follow serially the response of each alloantibody to a red blood cell antigen found in the mother's serum during pregnancy. If the
antibody is of IgG structure and directed against a red cell antigen inherited by the baby from its
father, the possibility for Hemolytic Disease of the Newborn (HDN) exists. Rh HDN is the most
common. Antigen-positive red cells from the baby will usually stimulate the mother to produce
more antibody, producing a rising titer.
Special Collection for Cold Agglutinin
Blood should be collected in a prewarmed (37o C) purple top vacutainer tube immediately placed
in a cup of warm (37o C) water and taken directly to the Blood Bank.
Direct Antiglobulin Test (DAT)
The DAT is used to detect globulins immunologically bound to the patient's red cells in vivo.
The test is used in the diagnosis of hemolytic disease of the newborn, autoimmune hemolytic
anemia, investigation of transfusion reactions, and diagnosis of drug-induced red cell
sensitization reactions. A cell eluate may be performed when the DAT is positive in order to
determine the identity of the antibody coating the cell. An eluate is the solution recovered after
attempting to remove antibodies from red blood cells. Several techniques are available and the
technique used will depend on the circumstances in each case. After an eluate is prepared, it is
tested in the same manner as serum to detect antibodies. Occasionally a cell eluate may
demonstrate the presence of an antibody coating the cell which cannot be detected by performing
a routine antibody screen. The test is also used in investigation of transfusion reactions if the
DAT becomes positive after the patient has been transfused.
Antigen Profile
The profile consists of typing the patient's cells for common antigens in the ABO, Rh, Kell,
Kidd, Duffy, MNS, Lewis and P blood group systems for which antisera are available. Patients
whose cells lack antigen in any of these systems have the potential to produce antibodies against
those antigens if the patient receives blood possessing those antigens. When the DAT is
positive, the extent of typing in the profile is reduced. An antigen profile is suggested for anyone
expected to receive serial transfusions over a long period of time such as patients with renal
disease, malignancies, chronic anemia, or other blood dyscrasia.
Transfusion Reaction Evaluation
Any symptoms suggestive of a transfusion reaction during or after a transfusion must be
reported to the physician and the Transfusion Service Lab for investigation. Post transfusion
samples must be drawn immediately. The investigation is a stat work-up consisting of 1) a
clerical check for errors, 2) inspection of plasma for hemolysis, 3) a DAT, and 4) visual
inspection of a post transfusion urine specimen. Any indication of a hemolytic reaction will
result in additional tests being performed. Please refer to Adverse Reactions to Transfusions.
Platelet Antibody Studies
The Blood Bank sends testing for post-transfusion purpura (PTP) and Neonatal Alloimmune
Thrombocytopenia (NAIT) to the Red Cross. The majority of PTP cases are associated with
anti- PLA1 antibodies, although other specificities do occur. Antibodies are detected during the
acute phase of thrombocytopenia, and platelet antigen typing is completed when the patient's
platelet count recovers. NAIT is caused by passive transfer of maternal antibody to the newborn.
The mother's serum is tested against the platelets of the father and a panel of known, typed
platelets. Specificity is often found to be anti-PLA1, but specificities with Bak, Yuk, Br, and
HLA are reported.
HLA ABC and DR typing and HLA Cytotoxic Antibody Testing
HLA ABC and DR typing is usually performed on potential bone marrow transplant candidates.
HLA ABC and HLA cytotoxic antibody testing is usually performed on patients about to
undergo chemotherapy for possible HLA matched platelet pheresis support in the event the
patient becomes refractory to platelet transfusions. Testing requires a calculation of the number
of tubes to be drawn based on the patient white count. Advance scheduling is also required. It is
therefore necessary to contact the blood bank prior to ordering testing.
Pretransfusion
Neonatal Typing
Tests performed include ABO, Rh, and DAT. Neonatal Typing should be ordered when sending
cord bloods or other specimens for testing of neonates or infants less than four months of age.
Type and Screen
This is not an order to perform compatibility testing, but to perform all testing required (ABO,
Rh, and antibody screen) prior to compatibility testing. Compatibility tests will only be
performed when there is a physician's order for transfusion.
Type and Crossmatch
This test includes ABO, Rh, antibody screen, and crossmatch of blood for transfusion. The
physician's order to transfuse or crossmatch blood for the patient must be written as it appears on
the chart.
Rh Immune Globulin (RhIg) Evaluation
Antepartum, amniocentesis, or termination of pregnancy - This work-up is performed to
evaluate the need for giving Rh Immune Globulin (RhIg) and consists of an ABO and Rh and
antibody screen. All pregnant Rh negative women should be evaluated as candidates to
receive RhIg.
Postpartum - After delivery, the newborn's blood type will be determined. If the baby is Rh
negative, the mother does not need a RhIg Evaluation. If the baby's type is Rh positive or
cannot be determined, the mother is a RhIg candidate and a postpartum sample must be
collected. This sample will determine if the mother should receive more than one dose of
RhIg.
Therapeutic Products
See "Circular of Information for the Use of Human Blood and Blood Components" (prepared by
AABB and ARC) or specific product circulars for commercially prepared products. The last ten
products in this section (12-21) are commercially prepared.
Red Blood Cells (Leukopoor)
The red cells from a unit of whole blood that have been filtered to remove >99% of leukocytes.
Leukocyte-poor RBC's are used routinely for all RBC transfusions. Storage may be up to 42
days at 4oC depending on the coagulant used when drawing the unit.
Red Blood Cells (Washed)
The red cells from a unit of whole blood that have been washed and resuspended in normal
saline. Washed cells contain little or no serum proteins. After a unit has been washed, it can be
stored for only 24 hours at 4 oC. This product may only be ordered after consultation with the
Blood Bank Medical Director.
Red Blood Cells (Deglycerolized)
The red cells from a unit of whole blood that have been glycerolized and stored frozen up to ten
years. Prior to transfusion, the unit is thawed, deglycerolized, and washed. Deglycerolized cells
contain reduced numbers of leukocytes and little or no serum proteins. After deglycerolization,
the unit can be stored for only 24 hours at 4oC. This product may only be ordered after
consultation with the Blood Bank Medical Director.
Autologous Blood
Autologous transfusion refers to the transfusion of blood or blood components to the same
person who donated the blood. Patients wishing to donate autologous blood are referred to the
Blood Bank of Delaware. (A physician order is required.) The donor center then delivers
autologous units to the appropriate hospital. These units are kept in inventory until they expire.
Each unit donated for autologous use shall have a special tag permanently attached to the unit. A
tag with the heading, "Autologous Unit – For Autologous Use Only" indicates that the unit is not
acceptable for allogeneic transfusion.
Designated Donation
Designated donations are units drawn for transfusion to a specific patient, usually from family
members or friends of the patient. A tag with the heading, "Designated Donation" and the
patient's name and date of birth will be attached to the bag. Designated donors are tested for
infectious disease markers, therefore 72 hours is required before blood is available to allow for
testing. A husband is not recommended as a directed donor for his wife of child bearing age. If
the wife receives this blood, she may produce antibodies that may affect future babies and cause
hemolytic disease of the newborn. Designated donors are not collected at Christiana Care.
These donors are referred to the Blood Bank of Delaware.
Platelets (Apheresis, HLA-matched, Random Donor Pools)
Platelets for transfusion are obtained by donor platelet pheresis. Rarely, and only with the
approval of the Blood Bank Medical Director, pools of six random donor platelets prepared from
individual units of donated whole blood may be provided. For adults, ABO-compatible platelets
are preferred, but are not essential. Platelets are not routinely crossmatched, however,
crossmatching is required if the platelet product contains more than 5 ml of red cells. Platelets
can be stored for up to five days after collection.
Platelet pheresis products are now tested for bacterial contamination before being delivered from
the Blood Bank of Delaware. Testing is initiated before the products are sent, but results may
not be available before the platelets are transfused. Should a pheresis product test positive for
bacteria, the blood center will notify our Blood Bank. Our Blood Bank will quarantine the
product, as well as notify the physician if the product has been transfused.
Platelet pheresis is an effective way to harvest a therapeutic adult dose of platelets from one
individual donor. Platelet pheresis should contain 3x1011 platelets, and the plasma volume will
vary between 200 and 500 ml.
If approved by the Blood Bank Medical Director, six random donor platelet concentrates may be
pooled for transfusion. Each individual platelet contains not less than 5.5x1010 platelets in 50-70
ml of plasma. The pool of six platelet concentrates should, therefore, contain no less than 3x1011
platelets suspended in 300-420 ml of plasma. Once the pool is prepared, this product expires in
four (4) hours. The platelet concentrates in each pool are tested for bacterial contamination
before being issued.
If the plasma volume of the platelets is considered excessive the product may be centrifuged to
permit removal of the undesirable plasma. Following this centrifugation, the platelets must rest
for 1 hour without agitation, then be gently agitated for 1 hour to assure the resuspension
necessary for optimum function and survival before they can be transfused. This two-hour delay
must be considered by the physician when requesting reduced volume platelet transfusions.
HLA matched platelet pheresis may be requested from the blood bank for patients who
demonstrate refractoriness to platelet transfusion. The products are obtained by the blood bank
from Penn Jersey American Red Cross and require scheduling of product and preliminary HLA
A,B, and C typing, and tests for HLA cytotoxic antibodies.
A one (1) hour post-transfusion platelet count is recommended after each platelet transfusion.
This count should be used to determine the correct platelet increment for the patient, and helps
determine how the patient responded to the platelet transfusion.
When Rh positive platelets are transfused to Rh negative females of childbearing age (<50 y/o),
Rh Immune Globulin prophylaxis is required to prevent Rh immunization which could occur
due to the small amount of red cells in the product.
Granulocytes
This product is obtained by leukocytapheresis of a donor in which granulocytes are removed.
The product contains not less than 1 x 1010 granulocytes in 50-100ml of plasma and
hydroxyethyl starch (HES). The product can be stored for only 24 hours, however transfusion as
soon as possible after collection is recommended. Pretransfusion compatibility testing is
performed the same as for red cell transfusion. Reduction of plasma volume of this product is
undesirable unless the patient clearly presents a problem of volume overload.
Fresh Frozen Plasma
The plasma removed from a unit of whole blood and frozen within six (6) hours from the time of
collection. This product can be stored up to one year at -18oC from the date of collection. Once
thawed, FFP can be stored for 24 hours at 1-6oC. This product is not intended for use as a
plasma volume expander. Major indication for use is to supply plasma clotting factors.
Cryoprecipitated AHF
A blood component obtained from a unit of whole blood. This product is prepared by thawing
Fresh Frozen Plasma at 4oC and separating the plasma cryoprecipitate from the thawed plasma.
This product can be stored up to one year at -18oC from the date of collection. Once thawed,
cryo can be stored up to 6 hours at room temperature unless pooled. A pooled cryo product can
be stored for only 4 hours at room temperature. Individual bags are not assayed, however, each
bag should contain more than 80 units of Factor VIII in a volume of approximately 30 ml. Each
unit also contains approximately 150 mg or more of fibrinogen.
NOTE: The next five products are not issued without approval of the Transfusion Service's
Medical Director or his designate.
Factor VIII (Dried)
Pooled concentrate of human Factor VIII commercially freeze dried and stored in the Blood
Bank. This product is used for patients with Hemophilia A. Both monoclonal and recombinant
Factor VIII products are available.
Factor IX (Dried)
Pooled concentrate of human Factor IX commercially freeze dried and stored in the Blood Bank.
This product is used for patients with Hemophilia B. Both monoclonal and recombinant Factor
IX products are available.
Factor IX Complex (Factors II, VII, IX, and X, Dried)
This product is prepared from pooled human plasma and then freeze dried. Each vial is assayed
and labeled for Factor IX. More information regarding this product should be obtained from the
package insert. This product is used for patients with Hemophilia A with inhibitors to Factor
VIII.
Anti-Inhibitor Coagulant Complex, Dried
This product is prepared from pools of human plasma and then freeze dried. This product is
assayed in arbitrary "inhibitor-bypassing units", which are roughly equivalent to its content of
prothrombin complex protein. Use of this product is restricted to patients with inhibitors to
Factor VIII. More information regarding this product should be obtained from the package
insert.
Anti-thrombin III (AT-III)
This product is a sterile, lyophilized preparation of purified human anti-thrombin III. It is
indicated for the treatment of patients with hereditary AT-III deficiency in connection with
surgical or obstetrical procedures or when they suffer from thromboembolism.
Rh Immune Globulin (RhIG)
Rh Immune Globulin is a solution containing anti-D fractionated from carefully screened human
plasma by a cold alcohol method. This product is filtered to remove possible viral contaminates.
It is used to prevent the formation of anti-D antibodies by suppressing the antibody response to
the foreign Rh positive fetal cells in the Rh negative mother. RhIG should be administered as
soon as possible to Rh negative, non-immunized mothers (within 72 hours) after birth,
amniocentesis, spontaneous passage, or surgical removal of the fetus. If RhIG is not given
within the 72 hours, later administration (up to 30 days) should not be withheld. As of January
1984, the American College of Obstetrics and Gynecology recommends that antepartum RhIG
be given at 28 weeks gestation to all Rh negative women. When Rh positive red cells or
granulocytes are given to an Rh negative patient, the patient should receive RhIG to protect
against possible immunization due to red cells in these products. When Rh positive platelets are
given to a Rh negative female <50 years of age, the patient should receive RhIg to protect against
possible immunization due to red cell contamination in the product.
Immune Globulin Intravenous
Immune Globin Intravenous is a sterile solution of human IgG protein. It is indicated for the
maintenance treatment of patients who are unable to produce sufficient amounts of IgG
antibodies. Use of Intravenous IgG may be preferred to that of intramuscular immunoglobulin
preparations especially in patients with bleeding tendencies in whom intramuscular injections are
contraindicated. It may be used in disease states such as congenital agammaglobulinemia,
common variable hypogammaglobulinemia, linked immunodeficiency with hyper-IgM, and
combined immunodeficiency. Intravenous IgG is also used in the treatment of ITP, particularly
in young adults and children. Intravenous IgG should not be used in individuals who are known
to have had an anaphylactic or severe systemic response to Immune serum globulin (Human).
Individuals with selective IgG deficiencies should not receive intravenous or any immune
globulin preparation. See product circular for indications, contraindications, and dosage and
administration.
Cytomegalovirus Immune Globulin
CytoGam is a sterile lyophilized powder of Ig G. The purified immunoglobulin is derived from
pooled adult human plasma selected for high titers of antibody for CMV. CytoGam is indicated
for the attenuation of primary CMV disease associated with transplantation. The product is
indicated for transplant recipients who are seronegative for CMV and receive marrow or stem
cells from a CMV seropositive donor.
WinRho SD
WinRho SD is a sterile, freeze dried gamma globulin fraction containing antibodies to Rho (D).
WinRho SD is prepared from human plasma and is subjected to solvent detergent treatment to
inactivate enveloped viruses including Hepatitis B, Hepatitis C and HIV. WinRho may be
administered either intramuscularly or intravenously to prevent Rh isoimmunization or to
function as an IVIG. The product is routinely used intravenously when the patient would
otherwise require multiple doses of Rh immune globulin to cover a large fetal-maternal bleed or
an Rh negative patient receiving Rh positive red cells. WinRho also functions as an intravenous
immune globulin, but this product only works as an IVIG in Rh positive patients.
Requesting Products from the Transfusion Service Lab
Transferring Orders to Requisition
Promptly after the physician has written an order for tests and/or transfusion, the order is
transferred to a Transfusion Service requisition or ordered through CCS and checked by the
proper nursing personnel.
Notify the Phlebotomy Team if they are to collect the specimen. Every attempt should be made
to have the specimens collected as soon as possible and still minimize the number of
venipunctures performed on the patient.
Once the specimen has been collected, the specimen should be delivered to the Transfusion
Service Lab without undue delay.
Red Blood Cell Products - Red Blood Cells (leukocyte poor), Red Blood Cells (Washed), Red
Blood Cells (Deglycerolized), Autologous Blood and Designated Donor Blood.
These products are requested on a manual Transfusion Service requisition by transcribing the
physician's order from the chart in the area labeled "physician's order" or are ordered through
CCS. Immediately beneath the physician's order indicate when the product is needed for surgery
or transfusion and the urgency of the request. The requisition must accompany the patient's
specimen (one 10 ml EDTA purple top tube) when sent to the Transfusion Service Lab.
Specimens will not be accepted without a proper requisition. Type & Screen and Compatibility
tests will be performed prior to issuing the products for transfusion.
If a patient's requisitions and specimens are received in the Transfusion Service Lab and
additional units are requested, a requisition with the physician's order must be sent or an order
placed in CCS. Additional samples may not be necessary, however, the Transfusion Service Lab
should be called to see if new specimens are needed. The technologist in the Transfusion
Service Lab will advise on the need for specimens and requisitions. Cancellation of orders
should be transmitted to the Transfusion Service Lab immediately including cancellation due to
death of the patient.
Red Blood Cell products will be held for 3 days after the compatibility tests have been
completed. Blood units are automatically released 72 hours later and returned to inventory in
order to have blood available for other patients. If a patient is being transfused over a period of
days, a new sample must be collected every 3 days.
In cases of dire emergency when the patient's condition does not warrant waiting for completion
of compatibility testing, uncrossmatched blood may be issued. In such cases, an emergency
release form must be signed by the physician or by a nurse for the physician. The physician's
name must be printed on the form to ensure legibility. This form is supplied by the Transfusion
Service Lab and filed with the patient's records in the Blood Bank.
Recommended guidelines for ordering red blood cell products:
Pre-Operative Orders - Specimens and requests for products on patients scheduled for
surgery should be delivered as soon as possible to the Transfusion Service Lab prior to
surgery. The Transfusion Service Lab should be given additional advance notice if the
patient may require large amounts of blood. Blood can be made available for most problem
cases and patients with rare blood types when sufficient notice is given. However, the
presence of antibodies may require longer time to have compatible products available. All
surgical blood orders should comply with the Maximum Surgical Blood Order Schedule
(MSBOS).
Routine Orders - Orders should be checked "routine" when the patient is being electively
transfused or does not need urgent transfusion.
ASAP Orders - Orders should be checked "ASAP" only when the patient may need an urgent
transfusion due to risk of bleeding or unscheduled surgery. Specimens and requests will be
processed so the products will be ready 1 - 2 hours after receiving the specimens and requests
in the Transfusion Service Lab.
STAT Orders - Orders should be checked "STAT" only when the product is needed for Stat
Transfusion. All requests from the Emergency Department are considered STAT. In most
instances, products will be ready in less than one hour, however, products may be issued
prior to completion of compatibility testing (see Issue of Uncrossmatched Blood).
Issue of Uncrossmatched Blood - When a patient is in need of a Stat transfusion and the
situation does not warrant waiting for completion of the Stat procedures, O negative blood
will be issued to the physician upon obtaining a signed "Release for Emergency Issue of
Blood Products" form. A blood specimen from the patient must be available in the
Transfusion Service Lab.
Patients presenting problems in finding compatible products often require extended testing which
will take additional time no matter how the blood is ordered.
Platelets
This product is requested on a Transfusion Service requisition by transcribing the physician's
order from the chart in the area labeled for the physician's order or ordered in the CCS.
Immediately beneath the physician's order, indicate when the product is needed.
Once the patient has been Typed by the CCHS Transfusion Service Lab, specimens do not need
to be drawn unless requested by the Transfusion Service Lab. Compatibility tests are not
routinely performed. By order of the physician, the volume of plasma can be reduced when the
patient cannot tolerate excess fluids.
Granulocytes
The physician should call the Transfusion Service Medical Director to determine the efficacy of
this product for the patient and to set up a transfusion schedule for the patient. This product is
requested on a Transfusion Service requisition by transcribing the physician's order from the
chart in the area labeled for the physician's order or ordered through CCS. Immediately beneath
the physician's order, indicate when the product is needed. The requisition must accompany the
patient's specimen (one 10 ml EDTA purple top tube) when sent to the Transfusion Service Lab.
Type & Screen and Compatibility tests will be routinely performed prior to issuing the product
for transfusion. Reduction of plasma volume of this product is undesirable unless the patient
already presents a problem of volume overload. Follow recommended Protocol attached to each
bag for transfusion instructions.
Plasma Products - Fresh Frozen Plasma and Cryoprecipitate
These products are requested on a Transfusion Service requisition by transcribing the physician's
order from the chart in the area labeled for the physician's order or ordered through CCS.
Immediately beneath the physician's order, indicate when the product is needed. Once the
patient has been Typed by the CCHS Transfusion Service Lab, specimens do not need to be
drawn unless requested by the Transfusion Service Lab. Compatibility tests are not performed.
Commercial Plasma Products-Factor VIII, Factor IX, Prothrombin Complex (Factor
IX),Anti-inhibitor Coagulation Complex and Antithrombin III
These products are requested on a requisition by transcribing the physician's order from the chart
in the area labeled for the physician's order or ordered in CCS. These products must be approved
by the Transfusion Services Medical Director or his designate. Compatibility tests are not
performed.
Immune Globulin Products - RhIG, Immune Globulin Intravenous, Cytomegalovirus
Immunoglobulin and WinRho SD
These products are requested on Transfusion Service requisition by transcribing the physician's
order from the chart in the area labeled for the physician's order or ordered through CCS.
Compatibility tests are not performed.
Guidelines for Antepartum use of RhIG.
Antepartum RhIG is given to Rh Negative women at 28 weeks gestation.
Patient must be sent to the Medical Arts Pavilion Outpatient Laboratory or Clinic with a
written order for an antibody screening and the administration of RhIG
The RhIG will be administered prior to the screening test being completed. This spares the
patient having to wait while the tests are completed. Only in a rare instance is a patient likely
to receive the RhIG unnecessarily.
If the patient's insurance coverage requires that the type and screen be performed at another
laboratory, it is the responsibility of the ordering physician to confirm that the patient is a
RhIg candidate. For these patients, written order to administer the RhIg is necessary.
Guidelines for use of RhIG following Diagnostic Amniocentesis
All Rh negative women undergoing amniocentesis should be evaluated as RhIG candidates.
Transfusion Service Lab records must confirm patient is Rh negative.
Patients not having records in the lab to confirm their type should have a RhIG Evaluation
performed.
Guidelines for use of RhIG following Aborted Pregnancy.
All Rh negative women aborting should be evaluated as RhIG candidates.
A RhIg Evaluation should be done prior to releasing the product on the day of the abortion.
Guidelines for Post Partum use of RhIG
Labor and Delivery (L&D) will notify the Transfusion Service Lab of all Rh negative women
admitted to their department.
L&D will send cord blood specimens from every neonate delivered by an Rh negative female
to the Transfusion Service Lab for type and DAT.
After testing of the cord blood has been completed, the Transfusion Service Lab will inform
the nursing station of the results. Those postpartum mothers who need to be administered
RhIg will have a blood sample drawn and sent to the Transfusion Service Lab.
Candidates who should receive RhIG will be issued the standard dose of RhIG (300 ug of
anti-D). Any evidence of a large fetomaternal bleed during the RhIG Evaluation will result
in calculation of the proper dose in the Transfusion Service Lab and additional vials will be
issued for the patient. After the RhIG has been injected, the chart copy of the Transfusion
tag must be placed on the patient's chart and the Transfusion Service Lab copy returned to
the Transfusion Service Lab.
Collection of Specimens
Good transfusion therapy relies on proper patient identification and specimen collection. The
following guidelines were designed to ensure positive identification of the patient and reduce the
possibility of errors occurring. These guidelines apply to all specimens collected for use in the
Blood Bank Department.
Prior to collection of any specimens, the proper requisitions for ordering tests must be stamped
with the addressograph plate or handwritten with the proper patient information. CCS
requisitions have the patient information already printed on them. Minimum identification on all
specimens and requisitions is:
Patient's full name
Medical Record, Emergency Department or Social Security number
Date and time of collection.
Signature of phlebotomist (label on specimen must be initialed).
Specimens submitted to the Transfusion Service Lab may be collected by a physician, staff
nurse, member of the IV Team or member of the Phlebotomy Team.
The patient must have an identification bracelet on their wrist or ankle prior to collection of
specimens. This applies to all in-patients and to those out-patients having specimens drawn for
transfusion. Out-patients having diagnostic tests performed (non-transfusion specimens) do not
need identification bracelets. Specimens for use in the Blood Bank must not be collected if the
patient does not have an identification bracelet on. If a bracelet is removed for any reason, the
person removing the bracelet or a person who observed its removal must place it on or affix it to
the patient. This is of utmost importance since a physician must take complete responsibility for
transfusion of a patient who does not have an identification bracelet attached to them. If the
physician does not want to take the responsibility, a new identification bracelet must be attached
to the patient, new specimens drawn, and submitted for repeat testing. The repeat testing will be
charged to the patient's account.
Identification information on the bracelet must be identical with the information on the
requisition and the specimen tube. Any discrepancies must be corrected prior to drawing the
specimen(s).
The phlebotomist must confirm the patient identifying information on the identification bracelet,
requisition, and specimen labels prior to drawing the specimen, and must sign his/her name on
the requisition to document the identification procedure.
Deliver the specimens without delay to the Transfusion Service Lab. All specimens for
compatibility testing must be accompanied by a requisition ordering the test(s).
Specimens for compatibility testing are used for 3 days. Check with the Transfusion Service Lab
if there is any question about specimens for compatibility testing.
Transferring Patients
The Transfusion Service Lab should be notified if a patient who has blood products being
prepared or held for transfusion or surgery is transferred to another Hospital. In order to assure
continuity of care, prevent undue delays in providing blood products, and prevent duplicate
testing and charging for the patient, the following guidelines are recommended:
From the Emergency Department
Any patient transferred from the Emergency Department to another unit or Hospital must keep
their Emergency Department identification bracelet on for 3 days, otherwise, products that are
available must be retested with a new specimen.
The Emergency Department should notify the Transfusion Service Lab when a patient is being
transferred and to which Hospital the patient is going. The Transfusion Service Lab will arrange
to have available blood products transported independently or with the patient. Products
transported with the patient must be immediately sent to the Transfusion Service Lab upon
arrival. (See Note). The unit receiving the patient should contact the Transfusion Service Lab to
inform them that the patient has arrived and confirm that the blood products ordered in the
Emergency Department are available.
Between CCHS Hospitals
A unit clerk or other personnel from the nursing station should notify the Transfusion Service
Lab when a patient is being transferred. The Transfusion Service Lab will arrange to have
available blood products transported independently or with the patient. Products transported
with the patient must be immediately sent to the Transfusion Service Lab (See Note). The unit
receiving the patient should contact the Transfusion Service Lab to inform them that the patient
has arrived and confirm that the blood products ordered at the other Hospital are available.
NOTE: The Transfusion Service Lab may also be sending the patient's specimens with the
blood products and it is of the utmost importance that the entire package be delivered to the
Transfusion Service Lab without delay.
Equipment needed for Transfusing Therapeutic Products
A.
B.
C.
Obtain the following from the Nursing Department
1. I.V. pole
2. Tourniquet
3. Adhesive tape
4. 70% alcohol prep and/or iodine tincture 2% sterile Sepps
5. Dry Sterile 2” x 2” sponges
6. Proper needle or plastic catheter
7. Covered arm board
All products for IV use must be filtered prior to infusion. Obtain one of the following
recipient sets from Central Service.
1. Blood Recipient Set (170 micron) - used for Red Blood Cell products; may be used for
plasma when a red cell product is also transfused.
2. Blood Component Recipient Set (170 microns) - used for plasma, platelets,
granulocytes and cryoprecipitates given by I.V. drip.
3. Blood Component Infusion Set (170 microns) – used when transfusing via I.V. push
small volumes of Factor VIII, cryoprecipitate, platelets, etc. (Stocked in Transfusion
Service Lab Only).
4. Microaggregate Filter (20 micron without integral tubing)
a. Central Supply stocks the Alaris 20 Micron High Capacity depth filter and the 20
Micron Pediatric depth filter.
b. The 20 Micron Pediatric filter is used routinely for infant transfusions. (see 5
below).
c. The 20 Micron High Capacity filter is used in adults and children for fast,
massive transfusions. It is used during surgery and in the Emergency Department
for trauma patients. An IV tubing set or a blood recipient set must be attached to
the 20 Micron High Capacity filter for utilization.
d. These filters must not be used to transfuse granulocytes.
e. Commercial microaggregate filters are available in 20 to 40 microns with or
without integral tubing. The types of filters available are either depth, screen or a
combination of depth and screen.
5. Neonatal syringe set (with 150 micron filter) – Recently there has been manufacturing
delays with the 20 micron pediatric filter (see 4 b. above). When supplies are
jeopardized, Christiana Care also provides the chartermed neonatal syringe set. This
device includes a 150 micron filter attached to a syringe and is designed for removal
and filtration of red blood cells into the syringe for administration to infants. This
device is also available in central supply.
Leukoreduction filters
1. If leukopoor red cells are not available from the Blood Bank, a red blood cell
leukocyte reduction Y-administration set will be issued from the Blood Bank with the
rbc. These are intended
for the leukocyte reduction of red cell products by direct
2.
in-line filtration during transfusions.
Some platelet products will be issued from the Blood Bank with a platelet leukocyte
reduction Y-administration set. These are intended for the leukocyte reduction of
platelet products by direct in-line filtration during transfusion. Most single donor
platelet pheresis products are leukoreduced during processing and will not require
filters during the infusion process.
Preparing for the Transfusion
A.
B.
C.
IV Solutions
1. Isotonic Saline, Normal Saline - 0.9% NaC1 for IV use only, is the only IV solution
which may be used in a blood recipient set before, during, or after transfusion of a
blood product. 50 ml of normal saline may be added to RBC to reduce viscosity.
2. Solutions containing dextrose may not be used as they cause hemolysis of red blood
cells.
3. Lactated Ringers (with or without dextrose) may not be used because of the Ca
content which also causes red blood cells to clump.
4. Any solution may proceed or follow a blood transfusion provided that the blood
recipient set used in transfusing the blood product is not used.
Special Precautions
1. All products given intravenously must be administered through a blood set containing
a filter.
2. Do not store blood products in an un-monitored refrigerator or at room temperature in
any department. If there is any delay in starting the transfusion, return the unit
immediately to the Transfusion Service Lab. Any blood product not returned to the
Transfusion Service Lab within 30 minutes of issuing cannot be re-issued nor can the
unit be released to another patient. Blood stored in monitored refrigerators or packed
in wet ice by the Transfusion Service Lab are not subject to the 30 minute limit from
time of issue, however, if the blood is removed for transfusion, the 30 minute limit
will apply from the time it is removed.
3. Absolutely no drugs are to be added to a unit of blood or a blood component.
4. Before obtaining the unit from the Transfusion Service Lab, check and verify the
following items in the patient's chart.
a. Verify the physician's order.
b. Check for a signed and witnessed consent for transfusion. The permit must be
signed prior to starting the transfusion. In emergency situations, a written order
must be obtained from the physician assuming responsibility for the transfusion if
consent from patient or relative cannot be obtained.
c. Check the chart for any previous Blood Bank reports.
d. Note if previous records confirm the patient's blood type.
Obtaining Products from the Transfusion Service Lab
1. Blood products should be obtained from the Transfusion Service Lab after all other
supplies are available in the patient’s room.
2.
D.
The IV nurse will be responsible for obtaining products(s) from the Transfusion
Service Lab only if she is starting the transfusion. Staff members who are starting
transfusions are responsible for obtaining the product from the Transfusion Service
Lab. Only nurses who have received additional training in transfusion therapy from
the IV Team are permitted to start transfusions.
3. Upon completion of pre-transfusion testing, the Transfusion Service Lab will call the
floor.
a. The floor in turn will call the IV nurse, if she will be starting the transfusion.
i.
The IV nurse will call the Transfusion Service Lab with the patient's full
name, medical record number and type of product to be administered. The
Transfusion Service Lab will then dispense the product(s).
ii. If two (2) patients with established IV lines acceptable for transfusion are to
receive red cell products, the IV nurse may take the product for both
patients out of the Transfusion Service Lab at the same time.
iii. For those patients who must have an IV started in order to administer the
blood, only one (1) unit at a time may be taken out of the Transfusion
Service Lab.
iv. The IV nurse may continue to take a plasma component and red cell product
out of the Transfusion Service Lab on two(2) different patients, whether an
IV line must be established or not, however, the red cell product must be
started first.
v.
IV nurses only may take one type of component to a third patient in any of
the situations above.
b. If the floor nurse will be starting the transfusion, she will send another nurse, a
unit clerk, or a service assistant to pick up the blood or product(s). Blood can be
sent through the tube system if it is available. If received via the tube system, the
transporter must sign the transfusion tag indicating that the unit received is
identified for the intended recipient. It is necessary to call the blood bank with
the patient's name, medical record number and products requested.
i.
The person picking up the product(s) must present an addressograph label of
the patient who will be transfused to the clerk or tech in the Transfusion
Service Lab.
ii. The type of product requested must be written on the label to confirm the
type of product ordered by the patient's physician.
iii. "Transport" personnel may pick up red cell products for two different
patients at one time. However, they must be taking the products to patients
on the same or adjoining nursing units.
iv. Red cells for one patient and one type of component (platelets, FFP, or
cryo) may be issued for another patient, or one type of component may be
issued for two different patients.
v.
If the patient is on dialysis, 2 red cell units for the same patient may be
dispensed at one time.
Confirmation of Patient Identity Prior to Transfusion
At the patient's bedside the transfusionist and one other licensed staff member must verify
and confirm the patient's identity. The following steps are the minimum required for
identifying the patient. It is the responsibility of the transfusionist for making any
additional checks deemed necessary.
1. The transfusionist should obtain verbal identification from the patient when possible,
i.e., "What is your name?"
2. The staff member assisting in the identification must be another licensed CCHS
professional. He/she should confirm the identity of the patient by visual recognition
and by inspection of the patient's identification bracelet affixed to the patient.
(NOTE: Patients should not be transfused unless the identification bracelet is affixed
to the patient).
3. The transfusionist (RN) checks the following with the identifying assistant (another
licensed CCHS professional):
Blood bag vs. Transfusion Tag.: Check the unit number, blood product, compatibility
of ABO and Rh, and expiration date. The ID assistant should read this information
aloud to the transfusionist, then repeat by having the transfusionist read the
information back to the ID assistant.
At bedside, Transfusion tag vs. the patient identification armband: Check the patient’s
medical record number, newborn ID, or ED number, and the patient’s full name. The
ID assistant should read this information aloud to the transfusionist, then repeat by
having the transfusionist read the information back to the ID assistant.
4. Any discrepancies must be immediately resolved or the unit must be returned to the
Transfusion Service Lab without delay.
5. Performance of this procedure must be documented on the Transfusion tag. The
transfusionist's signature must appear beneath the verification statement on the
Transfusion tag. The staff member assisting in the identification must sign their name
beneath the transfusionist's signature.
6. The Transfusion tag must not be detached from the unit while the product is being
transfused. Exception: For patients in isolation, leave the entire tag on the outside of
the door after confirming the patient's identity.
Starting the Transfusion
A. Using a Straight Recipient Set
1. Transfusionist must gently mix the unit.
2. The blood recipient set should be inserted into the unit by performing the following
steps:
a. Close all clamps.
b. Push coupler cover of transfusion tubing toward flange and twist to break seal.
Do Not Remove.
c. Pull apart tabs to expose one of the ports in the unit (outside port preferred).
d. Remove coupler cover and insert coupler using a twisting motion. Insert the
coupler as far as possible maintaining sterility of the system.
e. To prevent puncturing the unit with the coupler of the recipient set, the following
has been recommended:
i. Hang the unit from an IV pole.
3.
4.
5.
6.
7.
ii. Grasp port with tabs open.
Hold coupler immediately beneath flange. Insert coupler of recipient set as far as
possible with a twisting motion until firmly seated. Do not grasp filter, twisting the
filter may cause the seal to break between the filter and coupler.
Use of this technique causes pressure to be exerted by the blood or plasma against the
sides of the unit resulting in a clear entrance of the coupler into the unit. CAUTION
MUST BE USED. Ambient air should never enter the bag.
Fill the filter chamber completely using one of the following methods:
a. Remove unit from pole
b. Squeeze and hold unit upright, open clamp to fill chamber completely.
c. Close clamp and hang unit back on IV pole.
Or
a. After inserting coupler into the unit, squeeze filter chamber.
b. Release filter chamber to permit partial filling of chamber.
c. Squeeze and release filter chamber until completely filled.
Fill the drip chamber 1/4 to 1/2 full by squeezing and releasing the drip chamber. If
drip chamber should overfill, then invert unit, squeeze both filter and drip chamber.
Flow clamp should remain closed. Rehang unit and check that filter and drip chamber
are properly filled. Drip chamber visibility will return in approximately one minute.
Never remove recipient set from the bag.
Remove protector cap from needle adapter. Release clamp and expel all air from
tubing. Close clamp and keep needle adapter sterile.
Apply a tourniquet and select a vein. Release tourniquet.
After selection of the vein most suitable for venipuncture, the site should be prepared
by using venipuncture site preparation for donors (See BB Procedure Manual) or by
using the following procedure:
a. Scrub the venipuncture site with a sterile alcohol swab-isopropyl alcohol, 70%.
Use enough pressure to raise a redness in an area 1 1/2 to 2 inches in diameter.
Dry with a sterile 2 x 2 gauze sponge.
b. Using a sterile iodine tincture, 2% with alcohol 47% "Sepps", start at the site of
the intended venipuncture and apply the solution in concentric circles to cover an
area of at least 1 1/2 inches in all directions. Always apply at the outside of the
circle, never go back to an inner circle. Allow solution to air dry. (The minimum
drying time in emergencies is 30 seconds).
c. Using a sterile alcohol swab-isopropyl alcohol 70%, remove the iodine tincture.
Start at the site of the intended venipuncture and work out in concentric circles as
in the preceding step. Several alcohol swabs may be needed.
d. Dry area with a sterile 2 x 2 gauze sponge, being careful not to contaminate
venipuncture site.
e. Keep venipuncture site covered with a sterile 2 x 2 gauze sponge until ready to
insert the intravascular device. The prepared skin should not be touched until
after the device has been inserted beneath the skin.
Apply tourniquet, perform venipuncture, check for return flow, and release
tourniquet. If a catheter was inserted, remove the style at this time. Attach the
needle adapter of the recipient set to the needle or catheter.
9.
Secure needle or catheter in place with tape. Cover venipuncture site with a doubled
dry sterile 2 x 2 gauze sponge and tape in place.
10 The rate of infusion of a blood product depends on the clinical status of the patient.
The rate should be no slower than four hours per unit and the flow rates serve only as
guidelines. See Transfusion Rates. Adjust flow rate to 1 ml/min (15 drops per
minute). This flow rate should be maintained for the first five to twenty minutes.
Flow rates for neonates and infants are slower, see suggested flow rates under
Transfusion Rates. During this time, remain with the patient and observe for signs of
a transfusion reaction. Most hemolytic reactions will occur within the first thirty
minutes.
11 Increase the flow rate after the first five to twenty minutes to a flow rate of 3 ml/min
or to a rate prescribed by the physician. Before leaving, make the patient comfortable.
Report the patient's condition to the nurses responsible for monitoring the patient. The
nurse should check on the patient every fifteen to thirty minutes while the patient is
being transfused.
B. Using a Y-type Recipient Set
1. Obtain the necessary equipment for starting an IV including a Y-type recipient set and
a 250 ml bag of normal saline. (NOTE: 50 ml of normal saline can be added to RBC to
reduce viscosity).
2. Close all clamps on the recipient set
3. Insert one lead of the Y-type recipient set into the saline bag.
4. Prime the filter and tubing with saline.
5. Apply a tourniquet and select a vein. Release tourniquet.
6. Prepare the venipuncture site as described in step 7 in the section on using a straight
recipient set.
7. Apply tourniquet, perform venipuncture, check for return flow and release tourniquet.
8. Secure needle or catheter in place with tape. Apply a 2 x 2 dressing and tape.
9. Open clamp from saline bag and clamp beneath filter, establish a very slow drip rate.
10. Obtain product from the Transfusion Service Lab.
11. Perform patient identification by following the procedure for "Confirmation of Patient
Identity Prior to Transfusion"
12. Gently mix the unit.
13. Attach unit to the recipient set following steps 2b. thru 2e. in the section on using a
straight recipient set.
14. Prime lead from the product by opening and closing clamp beneath product.
15. Close clamp under saline bag and open clamp under product.
16. Regulate rate of infusion by adjusting clamp beneath the filter.
17. Adjust flow rates as described in steps 10 and 11 in the section on using a straight
recipient set.
C. Use of Fenwal - Blood Warming System
1. Attach the blood warmer to an IV stand by means of the brackets on the back of the
warmer. Plug the warmer into a 110-120V outlet.
2. Newer models have on-off switches; turn switches on.
3. Wait approximately two minutes for temperature indicator to reach the green operating
range area.
4.
Check alarm and breaker systems as directed on the back of the warmer. Record on
Q.C. record. If any problems, warmer should not be used.
5. Close roller clamp of blood warming bag and attach warming bag to offset pins on
inner panel of the Blood Warmer. Close and lock door of warmer. DO NOT OPEN
DURING USE.
6. Prepare the unit for transfusion. Follow steps 1-4 when using a straight set, steps 1-3
when using a Y-type recipient set.
7. Attach recipient set adapter to bottom part of Fenwal Blood Warming Bag. A pressure
infuser may be used if necessary.
NOTE: Temperature gauge must be in operating range before transfusion.
8. Open clamp on tubing of blood warming bag. Allow blood to flow into bag by
opening clamp on the recipient set. Squeeze and keep outlet chamber flattened until
blood appears in outlet tubing of warming bag. When blood appears in outlet tubing,
close clamp of blood warming bag and release chamber. Fill chamber with blood to or
above the index line located on the side of the warmer. If a Y-type recipient set is
used, prime recipient set and blood warming bag with saline.
9. Open clamp of warming bag to expel air from tubing.
10. Proceed with venipuncture and transfusion as directed in steps 6-11 when using a
straight recipient set, steps 5-17 when using a Y-recipient set.
NOTE: If the temperature indicator goes beyond the green area into the red area,
either turn power switch off or unplug unit from electrical outlet immediately. Any
problems which cannot be corrected should be reported to an IV nurse.
D. Use of Fenwal - Pressure Infuser - Two sizes of pressure infusers are manufactured, 600
ml and 1000 ml capacity. Only the 600 ml capacity should be used with blood product
units.
1. Confirm connection of bulb hand pump and tubing assembly. Close air valve.
2. Insert plastic non-vented blood container with primed recipient set attached. Insert
through lower opening of mesh panel. The label on the unit should face away from
the mesh panel.
3. Insert unit until its hanger slot is past the mesh panel. Thread the fabric suspensions
trap through the unit hanger slot and the Fenwal tab on infuser. Suspend infuser and
unit by fabric strap. DO NOT SUSPEND BY HANGER SLOT OF UNIT.
4. Open flow clamp wide open and observe drip rate. Slow or negligible drip rates may
indicate:
a. unit not gently mixed prior to priming the recipient set
b. small fibrin clots blocking the port in the unit
c. an occlusion in the tubing (mechanical or physical)
d. improperly positioned intravascular device
5. For pressure infusion, inflate to desired pressure as indicated on gauge. (NOTE: The
pressure gauge is an approximate indicator only. The product is not designed for use
in monitoring arterial or venous pressure). Do not exceed 300 mm of HG on gauge.
Over inflation may damage the infuser.
6. Infusion flow rate may be adjusted by using the recipient set clamp. Pressure infusion
may be maintained by squeezing bulb pump as the product is infused.
7. To remove empty unit, open air valve to rapidly deflate infuser.
E. Use of Tycos - Pressure Infuser – Primary usage in Emergency Dept
1.
2.
3.
4.
5.
6.
7.
Turn pressure infuser crank handle clockwise to open position.
Insert plastic, non-vented blood container with primed recipient set attached. Insert
unit through lower opening and attach
to metal hook. The label on the unit
should face away from the clear plastic.
Turn crank handle counterclockwise until it will no longer turn.
Infuser is now loaded and ready for use. No further adjustments need be made.
Use metal loop in top handle for attachment to IV stand.
Open flow clamp wide open and observe drip rate. Slow or negligible drip rates may
indicate:
a. unit not gently mixed prior to priming the recipient set
b. small fibrin clots blocking the port in the unit
c. an occlusion in the tubing (mechanical or physical)
d. improperly positioned intravascular device.
To remove the empty bag, turn pressure infuser crank handle clockwise to the open
position and remove bag.
Transfusion Rates
1.
The rate of infusion depends upon the clinical condition of the patient being
transfused. The flow rates listed in the table will normally result in complete
transfusion of the unit as indicated by the transfusion time.
Product
Red Blood Cells
Granulocytes
RBC (Deglycerolized)
Fresh Frozen Plasma
Platelets:
Apheresis
Random
Concentrate
Factor VIII/Factor IX
Factor VIII (Continuous)
Intravenous
Immunoglobulin
Quantity
(unit)
1
1
1
1
1
Pool of 6-10
50 ml
1 vial
Specified by
M.D.
1 vial
Rate ml/min
3
Transfusion Time
3
10
1-2 hours
50-60 minutes
1 - 2 hours
15-25 minutes
5-6
10
10
See package insert
Specified by M.D.
30-45 minutes
30-45 minutes
5-10 minutes
I.V. push in most instances
See #2 below
See package insert
As ordered (usually 12
hours)
1 - 1 1/2
2.
3.
4
Continuous infusion of Factor VIII - continuous infusion of Factor VIII must be
performed using a volume control device, such as the Alaris Pump. The diluent must
be Normal Saline. No dextrose solutions may be used as the diluent. The order
should specify the number of units (IU) of Factor VIII to be infused and the volume of
diluent desired. The infusion should be monitored at least hourly, and the rate
adjusted as needed to maintain a steady even flow through the specified infusion
period as ordered by the physician. A major side effect that may be seen with this
type of infusion is localized phlebitis. Nursing personnel should carefully monitor the
patient for this symptom. If localized phlebitis occurs, the I.V. site must be changed
and the ordering physician should be notified. Continuous infusion must not be used
with Factor IX or Cryoprecipitate unless specifically ordered by the Medical Director
or his designate.
Flow rates should be slower than those suggested and times of completion of the
transfusion will be longer in the following cases:
a. Infants and children
b. Adults over age 60
c. Cardiac and Pulmonary disease patients
d. Chronic anemia patients
In these cases, the flow rate should be designated by the physician. If not written on
the chart, request information from the physician.
The following flow rates are suggested for neonates and infants, based on the weight
of the child:
Weight of Child
Flow Rate
Less than 1.5 Kg
0.5 ml/min
1.5 Kg or greater
1.5 ml/min
Monitoring Patients During Transfusion
A. Red Cell and Granulocyte Transfusion
1. Gently mix blood as often as necessary.
2. Remain with the patient for the initial 20 minutes of transfusion to assess suspected
reaction.
3. Check patient at least every 30 minutes for any untoward effects, discomfort,
infiltration at needle site and for signs of reaction.
4. Check patient's temperature, pulse, respiration, and the flow rate of the transfusion at
15 minutes and 30 minutes, then every hour during the transfusion and one hour post
transfusion. Transfusion should be completed within four hours. If vital signs remain
in the normal range, then vital signs are taken as per routine. Record the values on the
appropriate sheet on the patient's chart. Record hourly flow rate.
5. Visually inspect and record all voiding at the start and during the transfusion as to
time, amount, and color. This should be continued for at least 12 hours posttransfusion. This is a very important clinical notation if an investigation for a
hemolytic transfusion reaction is required.
6.
B.
Any portion of blood not administered to the patient MUST be returned to the
Transfusion Service Lab immediately. Reasons for not completing the transfusion
must be written on the copy of the Transfusion tag returned with the unit. DO NOT
REMOVE the recipient set from the unit if the transfusion is stopped prior to
completion. The unit must be kept sterile, including the recipient filter set by placing
a covered sterile needle on the end of the tubing. If for some reason, the recipient set
has been contaminated, please note on the copy of the Transfusion requisition returned
to the Transfusion Service Lab with the unit.
7. Patients who are being transfused should be accompanied by a qualified nurse when
transported to another area or between hospitals. This is especially important when
the patient is going to an area where a qualified nurse is not present to monitor the
transfusion.
Plasma, Platelets, and Pharmaceutical Products
1. Remain with the patient for the initial 20 minutes of infusion.
2. Check the patient for any untoward effects, discomforts, or infiltration at needle site.
Observe the patient frequently throughout the transfusion.
3. Any portion of a component not administered to the patient MUST be returned to the
Transfusion Service Lab immediately. Reasons for not completing the transfusion
must be written on the copy of the Transfusion tag returned with the product.
4. If clinical lab tests were ordered to be performed following transfusion, notify
phlebotomist or appropriate staff member for collection of samples.
5. Whenever possible, a qualified nurse should accompany the patient if transported to
another area or hospital while being transfused.
"Add Ons" and Discontinuing the Transfusion
1.
2.
When an additional unit of blood or a plasma component is to be transfused
immediately upon completion of the first unit, the following steps should be followed:
a. The recipient set from the first unit may be used. If fibrin clots appear to clog or
fill the filter, a new recipient set should be used. The recipient set should be
disconnected at the needle hub when starting the next unit through a new set.
Maintain the sterility of the set being replaced by placing a covered sterile needle
on the needle adapter.
b. When reusing the recipient set, hang the unit on the IV pole. Grasp the tabs
protecting the port, pull them apart, and fold back to expose the sterile port. Do
not contaminate the sterile port.
c. Close the clamp on the recipient set from the completed unit and remove the unit
from the IV pole.
d. Remove the recipient set from the empty pack, being sure to maintain sterility,
insert the coupler taken from the transfused unit into the port of the unit on the IV
pole. Insert the coupler with a twisting motion until it is firmly seated.
NOTE: Every additional unit must be checked vs. the patient ID band by the
transfusionist and an identifying assistant, just like the first unit.
Discontinue the transfusion by performing one of the following:
a. Add any IV solution after changing the recipient set
Or
b.
Remove the needle from the patient's arm and apply pressure with a dry sterile
gauze. Place a pressure dressing on the patient's arm after all bleeding has
stopped.
If a patient in an isolation area has a transfusion reaction, the unit and attached
recipient set must be sent to the Transfusion Service Lab. The unit and attached
tubing must be placed in a clear plastic bag and sealed. Return the unit and the
lab copy of the Transfusion tag to the Transfusion Service Lab.
Charting the Transfusion
1.
2.
The transfusionist must chart the following information on the transfusion requisition
and Water Balance Sheet (or ICU Flow Sheet) after starting the transfusion:
a. On the transfusion tag:
i.
Transfusionist signature certifying proper identification of the patient, the
product, and information on the tag attached to the product.
ii. Signature of licensed staff member assisting with the identification at the
patient's bedside.
iii. Date and time started
b. .On the Water Balance Sheet (or ICU Flow Sheet) at the patient's bedside
i.
Date and Time unit was started
ii. Product and amount
iii. CCHS number from unit
iv. Type of intravascular device used and where it was inserted
v.
Signature and title of transfusionist when venipuncture is performed
c. The Medication Administration Record (M.A.R.) should be used to chart infusion
of Factor VIII, Factor IX complex, and Immunoglobulin. If volumes are 50 ml or
greater, they must also be charted on the Water Balance Sheet.
Upon completed infusion of the product or if the transfusion was stopped prior to
complete infusion, i.e. a transfusion reaction, the nurse who discontinues the
transfusion must chart the following on the transfusion tag and on the Ancillary and
Nursing Patient Progress Report.
a. On the transfusion tag:
i.
Indicate whether or not the entire unit was transfused. If "no" is checked,
also indicate the approximate volume transfused.
ii. Indicate whether or not a transfusion reaction was noted.
iii. Enter the date and time the transfusion ended or was stopped.
iv. Place the chart copy of the transfusion tag on the "Laboratory Results" form
in the patient's chart.
b. On the Ancillary and Nursing Patient Progress Report (may be charted by the
nurse responsible for the patient at the end of the transfusion):
i.
Patient's general condition at the end of the transfusion
ii. Patient's 1 and 24 hour post-transfusion TPR
c. If the transfusion was stopped to investigate a reaction, also include on the
Ancillary and Nursing Patient Progress Report:
i.
Time reaction occurred
ii.
Time product discontinued
iii.
iv.
v.
vi.
vii.
d.
Patient's symptoms (be specific)
Type of IV solution and time administered
Time IV nurse or Transfusion Service notified
Time post-transfusion specimens were collected
Time physician was notified, name of physician, and whether or not orders
were received.
viii. Include BP with post-transfusion TPR
ix.
Amount, results of visual inspection, and time of all voiding. (NOTE:
Technologist may request specimen be sent for urinalysis as part of
reaction workup).
Any additional pertinent data relating to the transfusion or reaction investigation.
Adverse Reactions to Transfusions
Any untoward symptoms noted by the patient or attendant during any transfusion constitutes a
Transfusion Reaction. This must be evaluated STAT by the patient's physician. The I.V. nurse
or transfusionist and the Transfusion Service Lab should also be notified STAT so the
Transfusion Reaction work-up can assist the physician's evaluation.
The following are definitions/descriptions of the recognized types of transfusion reactions:
A. Hemolytic Reactions
1. Acute Hemolytic Reactions – Acute hemolytic reactions are the result of transfusing
incompatible or abnormal red cells and are characterized by their prompt destruction.
Symptoms may include chills, a burning sensation along the course of the vein being
used for the infusion, flushing of the face, fever and headache, pain in the lower back,
and often an oppressive feeling in the chest. Shock may be a prominent feature.
Severe reactions without clinical symptoms may occur in patients under anesthesia,
often seen as abnormal oozing of blood, hemoglobinuria, and a drop in blood pressure.
Hemolysis may be primarily intramuscular with hemoglobinemia/uria or extravascular
producing icterus. Severe hemolytic reactions usually cause renal damage.
2. Delayed Hemolytic Reaction - Delayed hemolytic reactions are the result of
transfusing incompatible blood which caused an amnestic immune response to either a
previous transfusion or pregnancy. The amount of antibody in the patient's plasma is
too low to be detected in pre-transfusion serological testing. The antibody may not be
detected until 2-20 days after the transfusion when a rapid increase in the antibody
concentration occurs followed by rapid destruction of the donor red cells. Typically,
there are no clinical symptoms at the time of transfusion. Several days after the
transfusion, the following clinical pathology may appear: 1) a positive DAT, 2)
spherocytosis noted in blood films, 3) a fall in the hemoglobin concentration, 4)
jaundice, and/or hemoglobinemia/uria. Clinical symptoms may accompany this
reaction if the hemolysis is sufficiently rapid.
B. Non-Hemolytic Reactions
1.
Febrile Reaction - May be caused by leukocyte incompatibility, leukocyte cytokines,
or by bacterial pyrogens. Reactions are characterized by chills and varying degrees of
fever during transfusion. The fever is usually self-limited and rarely biphasic.
Symptoms often do not develop for 60-90 minutes or later following the start of the
transfusion. Flushing may develop within five (5) minutes if the patient has a potent
leukocyte antibody. Fever may be accompanied by headache, flushing, tachycardia,
etc., and discomfort may persist for as long as 8-10 hours.
2. Anaphylactic and Allergic Reactions - When platelets or plasma are transfused, the
recipient receives many different plasma proteins and alloimmunization to a certain
plasma protein may cause a reaction. Reactions may be severe, characterized by
flushing, dyspnea, and hypotension; much more common are mild reactions
characterized by urticaria (hives). Allergic reactions are relatively frequent and are
seldom serious, but must be noted and treated. Chills, fever and edema may
accompany eruption.
3. Graft-Versus-Host (GVH) - GVH may develop in immunocompetent or
immunodeficient patients when transfused viable T-lymphocytes present in cellular
blood components engraft, proliferate and react against host tissues. GVH as a result
of blood transfusion may be fatal. Symptoms include fever, skin rash, liver
dysfunction, severe diarrhea, bone marrow suppression and infection. GVH can be
prevented by irradiating all lymphocyte containing blood components prior to
transfusion.
4. Circulatory Overload - Overloading produces a rise in central venous pressure, an
increase in the amount of blood in the pulmonary blood vessels, and a diminution in
lung compliance. Circulatory overload is characterized by headache, tightness in the
chest, and dyspnea, dry cough, and frothy sputum. Circulatory overload during
transfusion must be treated as a grave matter and a very close watch of the patient
should be kept during the next 12 hours
5. Alloimmunization - Immunization to cellular, protein, or other alloantigens is an
unavoidable risk from transfusion of blood products. Patients may become sensitized
and produce antibodies to any antigen which they lack, and which is present in the
transfusion product. The risk of sensitization can be estimated to be approximately
1% for each unit of blood transfused. Following antibody formation, future
transfusions may be more difficult since it will be necessary to select blood products
lacking the corresponding antigen.
6. TRALI – Transfusion related acute lung injury may occur if leukocyte antibodies are
present in the donor plasma. Such antibodies may cause leukocyte aggregation in the
lungs of the recipient and subsequent fluid collection.
C. Disease Transmission
1.
Post-Transfusion Hepatitis (PTH) - Transmission of hepatitis is the most frequent
serious complication of blood transfusion, constituting a hazard to the health and life
of the recipient. Clinical symptoms range from very mild subclinical hepatitis to
severe fatal liver necrosis. All blood products carry a risk of transmitting hepatitis
except those which are exposed to high temperatures, filtration or solvent detergent
treatment during their manufacture (such as albumin, gamma globulin, and plasma
protein fraction). The degree of risk depends on the number of donor exposures the
patient has. Of the several viruses known to cause hepatitis, hepatitis C is the most
prevalent cause of PTH followed by hepatitis B virus. Investigation of PTH involves
the patient's clinical symptoms, incubation period and serological study of hepatitis
markers.
2. Transfusion Associated Cytomegalovirus (CMV) - Newborns, especially preemies
may be at high risk for CMV infections associated with transfusion of blood products.
CMV infections may result in serious after effects or death in the newborn. Adults,
except those that are immuno-compromised, are at lower risk since most have had
silent CMV infections at some time in their lives and have produced antibodies to the
virus. Since the virus is carried in leukocytes, it is possible that infection would be
less likely if blood components that are leukocyte-poor are used.
3. Bacterial Contamination - The clinical syndrome of a reaction due to the infusion of
contaminated blood is dramatic and its detection is important. The reaction is
characterized by shaking, vomiting, and bloody diarrhea. As a rule, the patient goes
into profound shock. The shock syndrome is peculiar in that it is accompanied by dry
flushed skin and fever ("red shock"). Symptoms appear after a latent period of about
30 minutes and follow infusion of as little as 50 ml of blood.
4. Acquired Immunodeficiency Syndrome (AIDS) - The disease caused by a retrovirus
called human immunodeficiency virus (HIV). This virus can be transmitted through
transfusion of blood and blood products, however, immunoglobulin, albumin, RhIg,
and Hepatitis B vaccine have not been implicated in AIDS transmission. The virus
infects T-helper (T4) lymphocytes which causes loss of immune function and
regulation. The long-term prognosis for most persons infected with HIV is unknown,
but the mortality of full-blown AIDS is very high.
D. Temperature Guidelines - All elevated temperatures are of importance in reporting any
untoward effects resulting from transfusion.
1. If the patient's temperature prior to transfusion of a unit is 37.2oC (99oF) or below, a
temperature rise to 38oC or above must be reported to the Transfusion Service Lab
and/or I.V. nurse as a suspected reaction by the nursing personnel responsible for the
patient and the monitoring of the transfusion.
2. If the patient's temperature prior to transfusion of a unit is above 37.2oC (99oF), any
temperature rise of 1.0oC must be reported to the Transfusion Service Lab and/or I.V.
nurse as a suspected reaction by the nursing personnel responsible for the patient and
the monitoring of the transfusion.
3. Orders to “transfuse despite temperature” are not required. Either “1” or “2” above
must be applied when evaluating temperature increases.
4. The temperature taken prior to starting the first unit should be used as a base
temperature for "add on" units.
E.
Suspected Reactions and Reaction Workup - If a nurse notes any symptoms suggesting a
reaction, she must follow the protocol below:
1. Allergic urticarial reactions, (i.e., local erythema, hives, and itching when not
accompanied by fever or any other adverse effects) are the only type of transfusion
reaction for which it is not necessary to discontinue transfusion. The infusion should
be interrupted and an antihistamine administered. After relief of symptoms, the
transfusion is continued slowly. The Blood Bank must be notified that the patient has
had an urticarial reaction, but a reaction workup is not necessary.
2. For any other type of Transfusion Reaction - STOP THE TRANSFUSION
IMMEDIATELY. If using a straight recipient set, close the clamp on the recipient set.
DO NOT REMOVE RECIPIENT SET FROM BAG. Remove tubing from needle hub
maintaining sterility of tubing and unit and attach a covered sterile needle. DO NOT
REMOVE IV NEEDLE FROM ARM. Keep vein open by adding IV normal saline
(0.9% NaCl) using a new set. Any pre-ordered IV solution may also be used. If a "Y"
type recipient set is being used, clamp off the blood line and open the clamp on the
saline to K.V.O. rate. Recheck transfusion tag and blood label on patient ID band for
any errors.
3. Immediately notify the attending physician or resident for evaluation. Also notify the
Transfusion Service Lab. A post-transfusion blood sample (1 purple top tube) must be
drawn. The specimen, a Blood Bank requisition, the unit and attached tubing and
saline must be sent to the Transfusion Service Lab for performance of a STAT
investigation. After the transfusion is discontinued, K.V.O. with pre-ordered IV
solution or saline.
NOTE: The post transfusion blood sample is evaluated to determine if a clerical error,
ABO incompatibility, or other antigen- antibody mismatches have occurred with RBC
transfusions. If reactions are suspected with platelet transfusions, the product must be
stopped, the physician and Blood Bank must be notified, and the transfusion tag must
be completed appropriately to document the reaction, but a blood sample need not be
drawn because RBC hemolysis is not involved.
4. An accurate account of the reaction must be recorded in the patient's chart. The
following must be charted on the "Ancillary and Nursing Patient Progress Report":
a. Patient symptoms and/or complaints
b. Time reaction occurred and blood product discontinued
c. Time and type of IV solution administered
d. Time I.V. nurse or Transfusion Service Lab notified and post-transfusion
specimens were collected
e. Time physician notified, name of physician, and whether orders were received.
f. Amount, results of visual inspection, and time of all voiding (NOTE:
Technologist may request specimens be sent for routine urinalysis as part of
reaction workup).
5. Upon completion of the Stat Investigation; the technologist will call the floor nurse to
check on the patient's condition, obtain results of visual inspection of urine, and report
the remainder of the results of the Stat Investigation.
6.
If there is no evidence of a hemolytic transfusion reaction or bacterial contamination,
no further work will be performed. The results of the Stat Investigation will be
reviewed by the Medical Director of the Transfusion Service Lab and a written
summary report will be placed on the patient's chart.
7. If there is any evidence of a hemolytic transfusion reaction or bacterial contamination,
the technologist will request that the unit nurse initiate baseline studies for either
hemolytic reactions, bacterial reactions or both.
8. Criteria upon which the technologist will base this request are:
a. Evidence of a clerical error that results in a hemolytic reaction
b. Positive direct antiglobulin test on a post-transfusion specimen and subsequent
recovery of an antibody when none was present in the pre-transfusion sample.
c. Evidence of hemolysis in the plasma and serum of post transfusion specimens
d. Any symptoms suggestive of a hemolytic reaction such as pain in the flank or
back, burning sensation along vein in which blood is infused, or excessive oozing
in patients under anesthesia.
If any of the above criteria are noted, consult a physician and administer 40 mg of
Lasix IV Stat.
9. Directions for all forms used in ordering baseline studies are:
a. All tests must be ordered STAT.
b. When using a manual requisition, the following must be written above the
patient's name: "Transfusion Reaction Evaluation" -- This will clearly identify
results as part of the baseline study so tests will not be charged to the patient.
c. The transfusion reaction work-up may also be ordered directly through CCS.
d. All tests must be drawn Stat and may be collected by a member of the
Phlebotomy Team.
e. All forms and specimens must be sent to the labs in which the tests are
performed.
10. Directions for initiating the baseline studies for a hemolytic reaction are as follows:
a. Blood Bank Studies - Order STAT, a Type and Screen using a Requisition by
checking the box marked Transfusion Reaction Evaluation. One EDTA (purple
top) tube must be sent to the Transfusion Service Lab. This specimen is for
additional testing not performed during the STAT Investigation.
b. Chemistry Studies - The following chemistry tests should be drawn STAT:
i.
Bilirubin (a second sample must be collected 5-7 hours after the
transfusion).
ii.
BUN (urea nitrogen)
iii.
Creatinine
iv.
Serum Haptoglobin
v.
Plasma Hemoglobin
A routine Chemistry form may be used to order the bilirubin, BUN, and
Creatinine. A Special Chemistry form may be used to order the plasma
hemoglobin and serum haptoglobin, or orders you placed through CCS.
c. Coagulation Studies - Order a STAT DIC workup using a Routine Coag form or
CCS orders. Two citrate (blue top) tubes, an EDTA (purple top) tube, and an FSP
tube should be sent to the Coag Lab.
d.
Urinalysis - Collect the first voided post-transfusion urine and send to Chemistry
for a STAT Urinalysis. When ordering, request a routine urinalysis including
microscopic examination.
11. The standing order for baseline studies of a bacterial reaction consists of a STAT
Blood Culture on the patient.
12. Directions for initiating the baseline studies for a bacterial reaction are as follows:
Order a Blood Culture to be drawn STAT. Use the Microbiology form, check the box
for blood specimen, and write on the line - Transfusion Reaction, or enter through
CCS.
13. Results of any baseline study will be charted on the patient's chart. After all tests have
been completed, the results will be reviewed by the Medical Director of the
Transfusion Service Lab and interpretation of the results will be placed on the patient's
chart.
Outpatient Transfusion
1.
2.
3.
4.
5.
6.
7.
Outpatient transfusions will be performed in the Ambulatory Infusion Center (AIC)
during normal operating hours, Monday through Friday. If the AIC is unavailable or
if a patient's condition requires, the patient may be admitted to an out-patient bed for
transfusion.
These patients are not to be admitted or held overnight unless a transfusion reaction
occurs and the physician in charge orders the admission. The staff nurse will notify
admitting after receiving the physician's admission order.
Outpatient transfusions in the AIC will be scheduled after the AIC nurse receives the
physician's order.
Transfusions in the AIC are performed following AIC procedures.
Outpatient transfusions that require a hospital bed must be ordered by the physician or
physician's office through the admitting office.
Admitting will prepare the outpatient registration and chart, and will also notify the
patient when to arrive at the admitting office.
Patients in a hospital bed will be transfused following procedure found in the Nursing
Procedure Manual for Blood/Blood Products.