Safe Transfusion Practice
Workbook
Diana Agacy Cowell
Specialist Practitioner of Transfusion
Pathology
Created by dagacy
1
Administration of Blood Components and Products
Safe Transfusion Practice
Table of contents
Learning outcomes
Introduction
Safe Transfusion Practice
Anatomy and physiology of blood
Red blood cells:
Normal Haematology values:
Platelets and Fresh Frozen Plasma (FFP):
Normal Coagulation Screen values:
ABO Blood Group
Rh D Blood Group
Haemolytic disease of the new born:
Sample Taking
Pre-collection checklist
Collection and Transport of Blood Components
Receipt of blood components in the clinical area
Administration of Blood components 6
‘Final bedside check’
Transfusion rate:
Care of patient being transfused 9
Observations required for a Blood Transfusion
End of transfusion: Disposal of empty packs
PROCEDURES6
Preparing for a transfusion
Checking the blood component
Transfusion of platelets
Transfusion of FFP
Transfusion of red cells
PATIENT MONITORING
If there has been a reaction do not discard the pack (see page 29
‘Procedure following reactions’)
Procedure for reporting adverse reactions
Types of reactions
Procedure following reactions
Appendix 1: Equipment Required for Transfusion 5
Cannulae / Venous Access Devices
Blood Giving Sets / Blood Administration Sets
Infusion Pumps
Pressure devices
Blood Warmers
Appendix 2: Adverse Reactions to a Blood Transfusion 5
Recognition of an acute adverse reactions
Types of Acute Reactions
Appendix 3:
MCQ
Glossary
References
Created by dagacy
page
3
4
6
7
8
8
9
9
10
12
12
14
16
16
18
20
20
21
21
21
22
23
23
26
27
28
29
29
30
31
31
34
35
35
35
36
36
36
37
37
37
40
42
44
46
2
Learning outcomes
Upon completion of this chapter, the reader should be able to accomplish the
following:
1. Define the purpose of a red cell transfusion, platelet transfusion and a
Fresh Frozen Plasma (FFP) transfusion.
2. Demonstrate a basic knowledge of the ABO and the Rh D blood
groups.
3. Identify the various stages of the Blood Transfusion Process.
4. Identify the difference between a Group & Screen sample and a CrossMatch sample, and the correct process of labelling these samples.
5. Identify the correct procedure of collection and transportation of blood
components.
6. Identify the equipment required for a blood transfusion.
7. Explain the safe process for the administration of different blood
components.
8. Discuss potential adverse reactions to a blood transfusion.
9. Discuss the risks of blood transfusion and identify the biggest risk of
transfusion. Explain how this risk can be completely eliminated.
Created by dagacy
3
Introduction
In an acute hospital setting the transfusion of blood components and blood
products is an integral part of everyday life however it is a finite commodity as
we rely on voluntary donors for its supply.
The National Haemovigilance
Office states that blood components and products are life saving and when
used appropriately they will improve the quality of life in a large range of
clinical conditions. However, it is also widely recognised, that as in any other
clinical intervention, there are a number of risks associated with this therapy,
transfusion transmitted infections (TTI) and human error. The quality of blood
has been given precedence over that of human error due to the impact of
hepatitis, human immunodeficiency virus (HIV) and more recently variant
Creutzfeldt-Jakob (vCJD) disease. However in the last decade the Serious
Hazards of Transfusion (SHOT) scheme1 has attributed most major incidents
to human error.
Safe Transfusion Practice relies on collaborative teamwork, as blood
transfusion is a complex, high risk and multi-step procedure. The Transfusion
Process crosses several professional boundaries and involves many
individuals. There are at least 23 stages between taking a pre-transfusion
compatibility blood sample, the recipient receiving their transfusion and the
completion of the transfusion.2 Six different professional groups intervene at
different stages of the process and with each stage there is the potential of
error.
In 2005 when the European directive for blood was transcribed into British
criminal law as the Blood Safety and Quality Regulations (2005)3 it became a
legal requirement that every unit issued for transfusion had to be fully
traceable from donor to recipient, vein to vein traceability.
The health
professional responsible for communicating the final fate of every unit in the
clinical area is the responsibility of the nurse as they are invariably the ones
that administer the transfusions on the wards.
To make this process easier
most hospitals, if they have not already, are in the process of implementing an
electronic tracking system to meet the above requirements. The laborious
Created by dagacy
4
paper systems, which might be still in use in some hospitals, are unreliable
and few have achieved 100% traceability as they rely heavily on the health
professional remembering to sign, date and return the traceability slip.
Despite this change from paper to electronic systems the transfusion process
will remain the same and the same safety steps will need to be followed.
With the transcription of the EU Directive on Blood Safety and Quality
Regulations in to British criminal law also came a new Haemo-vigilance
scheme which is monitored by the MHRA (Medicines and Healthcare
Products Regulatory Agency) known as S.A.B.R.E. (Serious Adverse Blood
Reactions & Events). This new scheme works alongside SHOT.
Created by dagacy
5
Safe Transfusion Practice
Patients should not be exposed unnecessarily to blood components and
products as there is always the potential risk of transfusion transmitted
infections, those that we are aware of and those yet to be discovered.
Therefore it is important to check the most recent haemoglobin result and
assess the patient for signs of anaemia. If the patient is not actively bleeding,
infection free and haemodynamically stable, query the transfusion, protect
your patient. Remember the use of blood requires a conservative approach
as the safest transfusion is the one not given.
•
It is important to follow procedure even though at times it can be quite
prescriptive but the evidence demonstrates that when we disregard
procedure errors occur.
Created by dagacy
6
Anatomy and physiology of blood
Blood is a highly specialised circulating tissue consisting of several different
types of cells suspended in a straw coloured fluid called plasma5.
Cellular Constituents
Red cells or erythrocytes
White cells or leucocytes
Platelets or thrombocytes
Function
Carry respiratory gases and give it its red colour
because they contain haemoglobin, an iron
containing protein that binds to oxygen in the
lungs and transports it to the tissues in the body.
Fight infection
Cell which play an important part in the clotting of
blood
The main components transfused are red blood cells (Rbc), platelets, plasma
(non-cellular) and cryoprecipitate (non-cellular). In this chapter we will focus
on the first three as they are the most commonly used components.
All components and products are derived from whole blood.
Red blood cells
WBC and platelets
Plasma
45%
<1%
55%
Whole blood
Picture 1
Plasma
Picture 2
Created by dagacy
Red cells
Picture 3
Platelets
Picture 4
7
The National Blood Service (NBS), part of the National Health Service Blood
and Transplant (NHSBT) take whole blood from voluntary donors. These
voluntary donations are then processed, to provide us with the components
we see in hospital 5.
Fresh Frozen Plasma
(plasma)
Packed red cells
(red blood cells)
Platelets
Blood components Picture 5
Red blood cells:
Red cells are prescribed to treat anaemia and haemorrhage.
Causes of anaemia:
• Iron deficiency
• Vitamin B 12 deficiency
• Folate deficiency
• Bone marrow failure
• Secondary to chemotherapy.
• Slow bleeding, especially from gastro-intestinal tract.
The diagnostic test used to detect anaemia is the ‘Full Blood Count’ (FBC).
One of the indices measured by this diagnostic test is the level of
haemoglobin (Hb) and it is this Hb level that is used to quantitate the degree
of anaemia.
The FBC is a valuable test for the diagnosis of anaemia as it provides other
valuable data which Haematologist use to differentiate between types of
anaemia.
Normal Haematology values:
Table 1
Haemaglobin (Hb)
Male
Female
g/dl
13-18
12-16
Adult
Critical values
x109 /litre
150-450
<30 or>7100
Platelet/thrombocyte count
Created by dagacy
8
Red cells are stored in refrigerators in the Blood Transfusion Laboratory (BTL)
or in designated refrigerators, often referred to as satellite blood banks or
satellite refrigerators. The temperatures of these refrigerators are strictly
monitored in order to preserve the quality of red cells. It is important to
maintain red cells at 2 o to 6o C. Therefore under no circumstances should red
cells ever be stored, even for a short period, in the ward refrigerator
Platelets and Fresh Frozen Plasma (FFP):
Platelets and FFP are prescribed to treat a coagulopathy. That is to stop
excessive internally or externally bleeding or in some circumstances to
prevent bleeding.
The FBC provides us with the number of circulating platelets (Table 1). While
the diagnostic test ‘Coagulation screen’ (CS) will indicate if FFP is required
depending on the International Normalised Ratio (INR).
Normal Coagulation Screen values:
Table 2
International Normalised
Ratio (INR)
Male
Female
Critical values
0.9 – 1.2
0.9 – 1.2
>5
FFP is stored frozen, hence the name, in the BTL and is defrosted before it is
sent to the clinical area.
Platelets are stored in an incubator at approximately 22o C on a ‘rocker’. The
gentle motion of the rocker prevents the platelets from aggregating.
Platelets should never be stored in a refrigerator.
Platelets and FFP are ordered on a named patient basis.
Patients borne after January 19967
In order to minimise the risk of transmitting new variant CJD these patients
should receive pathogen reduced FFP sourced from outside the UK. This
would either be methylene blue or solvent detergent treated FFP (Octaplas).
Created by dagacy
9
Blood groups
There are many blood group systems along with their sub-groups but at this
stage we will limit our attention to the two most clinically significant blood
groups, the ABO and the Rh D blood systems. All blood groups are inherited
and there are two ways of reporting the ABO blood group, the genotype or the
phenotype. The latter is the most common of the two.
ABO Blood Group
Genotype
Phenotype
Dad
Mum
A O
BO
Daniel
O
Lisa
O
Mary
AB
Recipient/Patient
ABO
Blood Group
Donor red cells
Compatible with:
Donor FFP
Compatible with:
Donor platelets
Compatible with:
A
A or O
A or AB
A or B or O
B
B or O
B or AB
B or A or O
AB
AB, A, B, O
AB
A or B or O
O
O
O, A, B, AB
O or A or B
Table 3
The table 3 shows which blood group each recipient is compatible or suitable
with depending on the component they need.
Created by dagacy
10
This choice is dictated by a substance that is present or absent on the red
cells of the recipient.
People who are blood group A have an ‘A’ substance (antigen)
on their red cell membrane. This ‘A’ substance stimulates the
production of Anti B Antibodies that will circulate in plasma.
The function of these antibodies is to defend the body from B
antigens which are present on the surface of B red cells and AB
red cells
A
People who are blood group B have a ‘B’ substance (antigen)
on their red cell membrane. This ‘B’ substance stimulates the
production of Anti A Antibodies that will circulate in plasma.
The function of these antibodies is to defend the body from A
antigens which are present on the surface of A red cells and AB
red cells
B
People who are blood group AB have both the ‘A’ and ‘B’
substances (antigens) on their red cells. The presence of both
the substances prevents the stimulation and therefore the
production of Antibodies in plasma.
AB
People who are blood group O do not have ‘A’ or ‘B’ substance
(antigens). Hence they produce A,B Antibodies in plasma.
O
The rationale for producing the specific antibodies is to defend the body from
what is foreign to it.
Example:
•
•
•
•
•
•
Elizabeth is blood group A and needs a red cell transfusion.
John is blood group B and wants to donate blood to give to Elizabeth.
However if John’s red cells are transfused to Elizabeth the anti B
antibodies in Elizabeth’s plasma will destroy John’s donated B red cells
causing haemolysis.
This will make Elizabeth very ill and it can be fatal.
Elizabeth can only receive type A or O red cells
The absence of AB antigens on O red cells make them safe to
transfuse to A, B or AB recipients.
Created by dagacy
11
Rh D Blood Group
In the past, though you will still hear the term used, this blood group was
referred to as the Rhesus blood group. However, the term Rhesus refers to
the species of monkey in which a similar antibody to that of the human version
was discovered. Using the previous example both blood groups would be
reported as:
Elizabeth is ‘A negative’ or ‘A Rh D negative’
John is ‘B positive’ or ‘B Rh D positive’
Negative means the absence of the Rh D factor on the surface of the red cell
membrane. Those that have this factor on their red cells are said to be Rh D
positive.
However, unlike the ABO antigens, the antibodies against the Rh factor are
developed either through placental sensitisation or transfusion. That is a
person who has never been exposed to the Rh D antigen will not posses the
Rh D antibody e.g.
Haemolytic disease of the new born:
Mother
Rh D neg
Biological father
Rh D positive
Foetus
Rh D Pos or neg ???
Rh status of the baby is unknown until it is born
If the foetus is Rh D negative like the mother there is no problem but if the
foetus is Rh D positive there could be a problem. Usually if it is the first
pregnancy the child is born without any problems however the risk increases
with future pregnancies. The problem occurs when the baby’s blood (RH D
positive) crosses the placenta into the mother’s circulation. When this occurs
the mother can become sensitised and her immune system will produce Rh D
Created by dagacy
12
antibodies. These Rh D antibodies will attack an Rh D positive foetus causing
haemolytic disease of the foetus and of the newborn.
1.
Mum
Rh D neg
Dad
Rh D positive
Foetus
Rh D
Pos or neg ???
2.
Mum
Rh D neg
Foetus
Rh D Pos
3.
Mum
Rh D neg
=
*
Y
*
Foetus *
Rh D Pos=
+
Y
Y
Y
Haemolysis
*
*
Y = antibodies
* = red cell breakdown
Some cases may warrant an intrauterine transfusion. If the baby is born with
a high billirubin count caused by haemolysis the baby will require an
exchange transfusion. In order to avoid this Rh D negative pregnant women
Created by dagacy
13
are offered preventive treatment with Anti D immunoglobulin however as it is a
blood product some women refuse this treatment.
Therefore it is important to always transfuse the right Rh D blood group. If a
child or adolescent is Rh D negative they must always receive Rh D negative
red cells and platelets. There can be exceptions to this rule during a major
incident or severe donor blood shortage however this is beyond the scope of
this chapter.
The Rh D status does not affect the transfusion of FFP or cryoprecipitate.
The Transfusion Process
Sample Taking
The transfusion process begins the moment a pre-transfusion sample is
taken. For this purpose a request form indicating the nature of the test
required must completed:
JH N
H AEM
07 89 12 3
S hep h ard
Jo hn
25/ 07/ 07
8. 45
Pr e - op , t o ns il le ct o m y
DAC
12 /0 3/1 96 0
S pr ing fo rd clo s e
S W1 6P T
G ro u p & Scr e e n
D r. H G reen
2457
A group and screen/save is required for the transfusion of all components.
Created by dagacy
14
For a cross-match the time, date and number of units required must be
specified on the request form. This test is requested when a patient requires a
red cell transfusion.
Before taking a blood sample the person taking the sample must first obtain
the patient’s or carer’s consent to take the sample and inform them of the
purpose of the test.
Use an open-ended question to identify the patient?
•
•
Are you Tommy Smith? X
Is this Tommy Smith? X
•
Can you tell me your full name and date of birth? √
•
Can you tell me this person’s full name and date of birth? √
All blood samples for the BTL must have the following information:
Patient’s:
• Forename
• Surname
• Date of birth (DoB)
• Hospital number or NHS number
• Gender
•
The person taking the sample must sign, date and time the sample tube as
well.
The sample label must be completed by the person taking the sample before
leaving the patient’s side or in outpatient clinics before the patient leaves the
room.
Created by dagacy
15
The labelling of blood transfusion samples in the event of a major incident or
for unknown/unconscious patients vary at different hospitals. The reader is
advised to find out what the local policy is for these situations.
Once all of the above has been completed send the sample to the Blood
Transfusion Laboratory (BTL).
No Identification wristband no transfusion
Pre-collection checklist
1. Patient is ready for the transfusion
2. Prescription on Transfusion Record, must include rate, date and
prescriber’s signature
3. Concomitant drugs are prescribed on the Drug Chart
4. IDENTIFICATION WRISTBAND in situ
5. Test patency of cannula
6. Do your baseline observation
7. Equipment required for the transfusion (Appendix 1):
• Transfusion giving set
• Pump (see hospital policy)
• Protective equipment, usually just gloves and apron, as per hospital
policy.
• 0.9% saline flush for intravenous access.
Collection and Transport of Blood Components
All blood components must be transferred from the site of collection e.g. BTL,
satellite blood bank etc to the clinical area in a box or non-transparent bag.
Blood components must be transferred directly from the collection point to the
clinical area and the person who receives the unit on the ward should take it
directly to the patient’s side in order to begin the transfusion immediately.
Blood components should only be collected or requested for delivery when the
patient is ready for the transfusion in order to avoid wastage.
Created by dagacy
16
To collect any blood component the person doing the collection must take four
points of patient identification (PID) to the blood bank and check these to the
Laboratory register, compatibility tag and National blood service label:
a)
b)
c)
d)
Forename
Surname
DoB
Hospital number/NHS number
Collecting Red Cells from a blood bank
fridge
2
1
3
Best Practice
Is when the
clinical area takes
the responsibility
to collect blood
from the
designated blood
bank
or return it
1. Check patient details on TR to Lab register
2. Check 14 digit unit number to Lab register
3. Check 14 digit unit number on compatibility tag to unit number on bag
and confirm patient details are exactly the same on the TR, Lab.
Register and compatibility tag.
Created by dagacy
17
Receipt of blood components in the clinical area
Best practice is for the nurse who is going to administer the blood transfusion
to go and collect the blood component. However, sometimes the collection is
delegated to a porter, health care assistant or another nurse.
The nurse
requesting the collection is responsible that the right unit is collected and
therefore must provide the person delegated to collect the component with
four points of patient identification. We recommend that the TR is used as
collection slip though an electronic picking slip will be used when electronic
blood track is implemented.
If it is a porter who is delivering the blood it is best practice for the nurse who
requested the collection to sign the receipt of delivery. The receipt slip should
include PID and the time of collection and delivery to the clinical area.
It is
important to patient safety and therefore the responsibility of the nurse to
check that the blood component being delivered is the right one for the right
patient.
‘Right Blood, Right Patient, Right Time’
Avoid night transfusions (SUHT Blood Transfusion Policy), this means
any transfusion that commences on the night shift, in any clinical area.
Night transfusions must be limited to emergency situations only e.g.
massive trauma or massive haemorrhage.
The blood component must never be left unattended.
On delivery to the
clinical area the unit should be checked at the patient’s bedside. NOT AT THE
NURSE’S DESK OR TREATMENT ROOM, this is bad practice and has been
Created by dagacy
18
the cause of severe morbidity and even mortality. As soon as the checking
procedure has been completed the transfusion must be commenced.
In some hospitals a single registered nurse may check and administer the
component. While in other hospitals two registered nurses are required for
the checking process however each nurse must check the details individually
in silence and then sign the relevant paperwork.
Created by dagacy
19
Administration of Blood components 6
‘Final bedside check’
Step 1:
Check 14 digit donation number on the NBS unit label to the Unit Identification
Label, if they match
Step 2:
Check patient information on Unit to Identification Label
to patient’s ID wristband, if the information matches
Step 3:
Prime the line with the blood component at the patient’s bedside/side and
commence the transfusion.
Step 4
Return compatibility tag to BTL as per policy
N.B See Appendix 3
Created by dagacy
20
Transfusion rate:
Red cells: For non-emergency transfusions the transfusion of red cells must
finish within 4 hours from the time the unit was taken out of the fridge. Most
red cell transfusions can be prescribed over 2 – 3 hours.
Platelets: Over 30 minutes
FFP: Over 30 minutes
Care of patient being transfused 9
Observations required for a Blood Transfusion
One Unit
Two Units and more
Baseline Observations
Baseline observations (taken at the end of
transfusion of previous unit)
At 15 minutes following start
At 15 minutes following start of each unit
At end of transfusion (this will form the baseline
observations for 2nd unit etc.)
At the end of each unit.
•
Further observations will depend on the clinical condition of the patient
or if the patient becomes unwell or shows signs of an adverse reaction
to the transfusion.
•
Unconscious patients can be difficult to assess for signs of adverse
reaction to the transfusion and must be closely monitored during the
first 15 minutes of each unit for any visual or vital sign changes.
•
It is good practice to remain with the patient for the first 15 minutes of
every unit transfused as this is when the majority of reactions occur.
This is why some text books recommend that the rate of transfusion
during the first 15 minutes should be slower than the prescribed rate.
Once the 15 minute vital signs have been checked and no change has
been observed from the baseline than the rate can be increased to the
prescribed rate.
Created by dagacy
21
•
It is important to physically observe the patient at regular intervals
during the blood transfusion and to warn the patient or carers to inform
a member of staff immediately should the patient become agitated or
develops a rash etc. (Appendix 2)
End of transfusion: Disposal of empty packs
•
Empty packs should be kept on the ward until the current transfusion
episode (one or more units in one session) is complete.
If the
patient’s observations have remained stable and no there have been
no signs of an adverse reaction the empty packs maybe disposed of
in ward clinical waste.
Created by dagacy
22
PROCEDURES6
Preparing for a transfusion
No.
1
2
Action
Consent
a) Formally identify the patient.
Explain the procedure to the
patient/carers.
b) Assess for any history of
reactions.
c) Obtain verbal consent from the
patient/carer for the transfusion
to take place.
d) Document in Transfusion
Record (TR) or in patient’s
medical notes
e) Give information to the
patient/carer and the need to
report problems, about the
potential side effects of
transfusion such as anaphylaxis
which may present as shivering,
flushing, shortness of breath,
pain in loins or feelings of
agitation.
Rationale
To establish positive
identification.
To prevent any reactions.
Give patient/carer information
leaflet to read to enable them
to have a full understanding of
the procedure (Essence of
Care, DOH 2001)6.
Patient/carer informed about
potential hazards of
transfusions and report early
indications or reactions
Medication Preparation
a) Under no circumstances are drugs
To comply with professional
to be added to any blood
standards of practice.
component / product.
b) If Paracetamol, Chlorphenamine or
Hydrocortisone to be given as cover
prior to transfusion or in the event of
a transfusion reaction occurring this
must be prescribed by the doctor
prior to transfusion commencement.
c) Check that the component/product
has been prescribed on the
Transfusion Record to ensure
correct transfusion of blood
products.
d) Do not prime giving sets with
normal saline 0.9%. Do not flush
giving sets post transfusion with
normal saline 0.9%.
Created by dagacy
To ensure correct transfusion
given.
23
No
Action
2
Medication Preparation (continued)
e) Blood must be prescribed on a
Prescription Chart or Transfusion
Record (TR) that contains the
patient’s ID number, surname, first
name and date of birth.
f) The prescription must state the
name of the blood component/
product to be transfused, the
volume to be transfused, rate of
transfusion.
g) A unit of red cells is usually given
over a minimum of 1 hour and a
maximum of 4 hours.
h) A unit of platelets or FFP is given
over 30 minutes.
3
Cannulation or Central Venous
access
a) Cannulate the patient according
to Cannulation Policy. Ensure
cannula is patent.
b) The choice of cannula used for
the procedure should be depend
on the individual and the desired
rate of infusion.
c) Assess the need to flush the
cannula (using a pulsating flush)
according to policy, prior to
transfusion and following
procedure.
d) Secure with non-allergic tape or
IV dressing depending on choice
of cannula.
e) Ensure cannula is well secured.
Rationale
Appropriate cannula is used
and individual patient needs
addressed.
To keep cannula patent and
therefore stop blocking.
Reduces the need for extra
trauma to the patients.
To avoid blood wastage if
access unobtainable.
Baseline Observations
4
a) Take the patient’s temperature,
pulse, respiratory rate
To have baseline vital signs
and/oxygen saturation and blood recorded and ensure that the
pressure prior to transfusion
patient is fit for transfusion.
commencing.
b) Document on Observation chart
or specific Transfusion Record.
If using ordinary observation
chart highlight that the vital signs
correspond to those recorded
during a blood transfusion
Created by dagacy
24
5
Collection or receipt of blood
component
a) To collect any blood component
the person doing the collection
must take four points of patient
identification (PID):
•
•
•
•
Forename
Surname
DoB
Hospital number/NHS number
b) The nurse requesting the
collection must provide the person
delegated to collect the component
with the four points of patient
identification.
Created by dagacy
25
Checking the blood component
No.
Action
1
Formally identify the patient and ensure
that the information matches the
Transfusion Record.
Rationale
2
Check that the 14 digit number on the
bar-coded National Blood Service (NBS)
label matches the compatibility tag (CT)
(luggage tag label attached to the bag).
4
Start time of unit must be recorded on
peel off section of CT, once the first few
mls have been transfused.
5
The third section of compatibility tag
(CT) needs to be torn off and completed
once the transfusion has started ideally
when doing the 15 minutes observation
post commencement.
6
The third section must be returned to the
blood transfusion lab. This is a legal
requirement under the Blood Safety and
Quality Regulations 2005.
Vein to vein traceability
7
Fill in the time of arrival of blood
component/product in clinical area.
Tracking of blood from Blood
Bank to recipient.
8
Each blood component/product must be
inspected for defects prior to their
infusion. Particular attention should be
paid to the following
a) Integrity of pack
b) Discolouration
c) Presence of clots
Faulty products will not be
infused.
Created by dagacy
The correct unit of blood will
be given.
26
Transfusion of platelets
No.
Action
1
Transfusion of platelets should be
commenced as soon as possible
following collection/receipt in the clinical
area.
Rationale
This component is used to
stop bleeding.
2
Always administer platelets before a red
cell transfusion
Platelets are given first in the
blood transfusion process as
they act to stop bleeding.
3
Platelets are stored at room temperature
(Ideally 22 oC but can be between 2024). Platelets should never be stored
in a refrigerator
Preserve the maximum
activity of platelets
4
If possible use a platelet giving set.
5
Agitate platelets before administering.
These giving sets are
shorter and it maximises
the volume infused,
therefore there will a better
increment and it is more
cost effective.
To prevent clumping.
6
Platelets are administered rapidly over
30 minutes. Carry out visual
observation for rashes, level of
consciousness and change in
respiratory rate. Monitor temperature,
pulse and blood pressure as for blood
transfusion.
As platelets are delivered
rapidly, a reaction is
possible.
7
Proceed as for blood transfusion.
Platelets are more likely to
react than red cells because
of the temperature at which
they are stored.
Created by dagacy
27
Transfusion of FFP
No.
Action
1
Transfusion of FFP should be
commenced as soon as possible
following collection/receipt in the clinical
area.
Rationale
This component is used to
stop or avoid bleeding by
correcting the INR.
2
Always administer FFP before a red cell
transfusion
FFP are given first in the
blood transfusion process as
they act to stop bleeding.
3
FFP should be returned to the BTL
within 30 minutes if it is not going to be
transfused.
Preserve FFP up to 24
hours, reduces wastage
4
Use blood component giving set.
6
FFP is administered rapidly over 30
minutes. Carry out visual observation
for rashes, level of consciousness and
change in respiratory rate. Monitor
temperature, pulse and blood pressure
as for blood transfusion.
As FFP is delivered rapidly,
a reaction is possible.
7
Proceed as for blood transfusion.
FFP are more likely to give
an allergic reaction owing to
plasma proteins.
Created by dagacy
It has the correct filter
28
Transfusion of red cells
No.
Action
1
Transfusion must commence no longer
than 30 minutes after delivery to the
ward area.
Rationale
Maximum time of transfusion
4 hours from time out of
fridge.
Avoid wastage
2
The red cells can only be used for the
person who is named on the
compatibility tag.
3
If time out of the refrigerator is uncertain
it must not be transfused but returned to
the BTL and the staff informed.
Risk of bacterial
contamination
4
All blood components/product must be
transfused through a sterile blood
product giving set which has 170-200
micron filter.
To filter micro-aggregates
and prevent the
accumulation of clots in the
filter. This is why a giving
set must never be flushed
post transfusion. It
increases the risk of clots
and adverse reactions.
5
The first 15 minutes of a red cell
transfusion should be transfused at a
slower rate than the prescribed rate.
Approximately 20 drops per minute.
Most moderate to severe
reactions will occur in the
first 15 minutes of a
transfusion.
6
Set the rate of the transfusion to 30 – 40
drops per minute for 1 unit of blood to be
administered over 2 hours.
To ensure correct delivery
rate.
PATIENT MONITORING
No.
Action
1
Patients who receive transfusion should
be monitored throughout the whole
process (BCSH, 1999)
2
Ensure that the patient is in a setting
where they can be closely observed and
they can access the nurse call bell.
3
Advise and encourage your patient to
notify you immediately if they begin to
feel anxious, or if they become aware of
any adverse reactions such as
shivering, flushing, pain or shortness of
breath.
Created by dagacy
Rationale
Risk of reactions.
29
4
Monitor the patient’s temperature, pulse
resp. rate and blood pressure 15
minutes after you begin the transfusion
of each unit, and record them on the
Transfusion record.
5
Once transfusion is completed record
post transfusion observations prior to
the removal of the cannula.
6
Once cannula is removed and site
secured, discard line in a yellow clinical
waste bag, according to clinical waste
procedures.
7
Discard the blood bag in this way unless
there has been a reaction.
If there has been a reaction do not
discard the pack (see page 29
‘Procedure following reactions’)
8
Complete documentation recording the
date and time transfusion ended.
Created by dagacy
Care of patient being
transfused
Safe disposal of waste.
Good record keeping is the
mark of a skilled practitioner.
(NMC,2002
Continue patient observation.
30
Procedure for reporting adverse reactions
An acute haemolytic transfusion reaction is almost always due to ABO
incompatibility. The most likely cause of such an incompatibility is patient misidentification by persons involved in the transfusion process.
Action for all suspected reactions ALWAYS:
No.
Action
1
Stop transfusion immediately.
2
Check
the
patient’s
Rationale
To prevent further reaction.
identity Right blood Right Patient
(verbally and/or ID wristband) to
the compatibility tag attached to
the unit.
3
Check unit label to compatibility Right blood Right patient
tag.
4
Get prompt medical evaluation
Assess patient
Types of reactions
No.
Action
1
REACTIONS MILD (Acute)
Signs and symptoms
Usually occur within the first 15
minutes of each unit.
A. temperature – a rise of 1.5 °c
above a patient’s baseline is
identified as pyrexial.
Give Paracetamol dose should be
calculated on the patient’s weight
to be effective.
Encourage patient to drink cold
fluids. Keep cool, sponge down as
necessary.
Contact Medical Practitioner
Rationale
Stop transfusion
Get prompt medical assessment.
To reduce severity of reactions.
If signs and symptoms subside or
do not get any worse, restart
transfusion at a slower rate but
continue to monitor / observe
patient closely.
B. urticaria rash (hives)
Contact the Medical Practitioner
Chlorphenamine should be
administered. Dose will depend on
the age of the child.
Created by dagacy
31
2.
3
MODERATE TO SEVERE (Acute)
Burning sensation along the vein,
while blood is being transfused.
Shock.
A feeling of faintness, loss of
consciousness, hypotension, chest
pain, loin pain, bronchospasm and
breathlessness. A rise in
temperature, urticaria, tachycardia,
rigors and haematuria.
Stop transfusion
Get prompt medical assessment
Leave cannula in for venous
access. Give Epinephrine dose will
be age dependent (see local
anaphylaxis protocol)
Check airway, breathing and
circulation. Commence CPR if
indicated.
Infective Shock
(Moderate to Severe – Acute)
For fluid infusion.
Bacterial contamination of Platelets
or, less likely, red blood cells.
Usually occurs with the first 100mls
of contaminated pack.
Stop transfusion
Signs and Symptoms
• Myalgia
• Shocked patient
• Hypotension
• Rapid pulse
• Raised temperature
• Rigors
• Possible wheeze / dyspnoea
Action
• Stop transfusion
immediately
• Inform Medical Practitioner
• Treat for shock
• Administer 100% Oxygen
via a re-breathe bag.
• Treatment includes prompt
medical attention for
septicaemia
Created by dagacy
To ensure no further blood
component is transfused.
The smallest amount of blood
component will cause a reaction.
32
No.
Action
Transfusion-related Lung Injury
This occurs when donor plasma
contains antibodies to the patient’s
white cells.
Extremely rare but may be life
threatening. Occurs during or soon
after transfusion.
4
Rationale
Stop transfusion.
Patient will require intubation.
Signs and Symptoms
• Acute respiratory reaction
with fever, cough, wheeze /
dyspnoea
• Pyrexia
• Tachypnoea
Action
• Stop infusion
• Aim to keep patient relaxed
• Inform Medical Practitioner
• Treat as per shock patient
Created by dagacy
To ensure no further blood
component is transfused.
The smallest amount of blood
component will cause a reaction.
33
Procedure following reactions
Re-check transfusion
documentation and inform BTL:
To establish any errors in patient
identification.
Return blood bag and giving set
to BTL plus any empty bags
already used.
To alert BTL of the possibility of
another patient being involved in
the mismatch.
RETURN ALL UNUSED UNITS
Blood samples will need to be
taken from the patient:
• 1 cross-match sample
• 1 EDTA
• 1 Sodium citrate
• 1 Heparin
• 1 clotted
• Cultures if there is
pyrexia
Blood is required by BTL for reanalysis, if possible.
Ensure that the adverse
reaction part of the transfusion
record is completed and return
a photocopy of the transfusion
record along with the above to
BTL immediately.
Information required for
investigation.
Take appropriate blood samples
from patient.
If a transfusion record is not
used the following information
must documented and sent to
the BTL.
• Vital signs before and after
incident
• Rate of Transfusion
• Patient’s clinical diagnosis
Created by dagacy
34
Appendix 1: Equipment Required for Transfusion 5
Cannulae / Venous Access Devices
Any size cannula can be used for transfusing blood products but choice must
depend on the size of the vein and the speed at which the product is to be
given.
Recommendations:
The needle diameter for transfusion of blood in adults is 18-19 gauge.
Needles as small as 23 gauge can be used in paediatric practice.
Blood Giving Sets / Blood Administration Sets
•
Do not prime the giving set with Sodium Chloride 0.9%.
•
If platelets and red cells are to be transfused give platelets first.
•
Do not transfuse platelets through a giving set that has
previously been used for red cells or other blood component as
this may cause aggregation and retention of platelets in the line.
•
It is strongly recommended that platelet- giving sets be used
because they are shorter and less platelets are left in the line at
the end of a transfusion.
•
Red cells and FFP MUST be transfused through a sterile giving
set designed for this procedure with integral mesh filter 170200µm pore size.
•
A screen filter should be used for paediatric patients if the
transfusion is being administered by syringe. The filter (170µm
pore size) is placed between the product bag and the syringe.
•
Giving sets with burettes should not be used for the transfusion
of blood components /products.
•
All giving sets should be primed with the blood product being
transfused.
•
If there is another red cell unit to follow of the same ABO group
the same giving set can be used.
•
If blood of a different ABO group is to follow the giving set
must be changed.
•
For patients requiring ongoing transfusion, the giving set should
be changed at least every 12 hours.
On completion of the transfusion take down the giving set. Do
not flush the giving set with Sodium Chloride 0.9%.
•
Created by dagacy
35
• A new giving set should be used if any other type of I.V. infusion
is to continue after the blood transfusion.
•
The cannula or central venous line must be flushed with Sodium
Chloride 0.9% prior to commencing any further infusions.
Infusion Pumps
Infusion pumps can be used to achieve optimal flow rate.
•
All paediatric red cell and FFP transfusions are administered via a
volumetric infusion pump.
•
When using any pump it is important to ensure that the giving set is
compatible with the volumetric pump.
Pressure devices
In large volume transfusions, the use of a pressure device is
recommended. The maximum pressure that should be applied to a
blood transfusion pack is 300mmHg.
Blood Warmers
Blood should only be warmed using a specifically designed commercial
device with a visible thermometer and audible warning alarm. The
manufacturers instructions must be followed.
Blood must not, under any circumstances, be warmed using any
other measures.
Blood warmers are indicated if:
•
The flow rate is >50 ml/kg/hr for adults
•
The flow rate is >15 ml/kg/hr for children and for exchange transfusion in
infants.
•
The patient has severe cold agglutinin disease where cold agglutinins may
be clinically significant.
Created by dagacy
36
Appendix 2: Adverse Reactions to a Blood Transfusion 5
If a transfusion reaction is suspected the transfusion must be stopped
immediately and the patient assessed.
Action for all suspected reactions:
1. Stop the transfusion.
2. Check the patient’s identity (verbally and/or ID wristband) to the
compatibility tag attached to the unit.
3. Check the 14 digit donor number on the unit label to the 14 digit on
compatibility tag. They should be identical.
4. Get prompt medical evaluation
Recognition of an acute adverse reactions
Acute adverse reactions occur during the transfusion commonly within the first
15 minutes from commencement of any unit.
Types of Acute Reactions
MILD - not life threatening, there can be signs of urticarial rash and/or a
temperature rise of less than 1.5°C above baseline.
To treat the urticarial rash give 10 mg of Chlorphenamine as a slow
intravenous bolus.
To treat the temperature give paracetamol
If the patient does not get any worst or symptoms subside the transfusion can
be re-commenced but at a slower rate of infusion. It is important to monitor the
patient more frequently. The reaction must be documented in the patient’s
medical notes.
MODERATE TO SEVERE – are those that compromise the patient’s condition
and require immediate attention.
1. ABO incompatibility or Haemolytic Reaction (OHR)
Created by dagacy
37
Signs and symptoms: Chills, restlessness/agitation, pain at infusion
site, Muscle in abdo/chest/lumbar region, oliguria and anuria (reduced
or no urine output), Haemoglubinuria.
Treatment:
Give Furosemide if urine output falls/absent. Treat DIC
with appropriate blood components.
2. Severe allergic reactions
Signs and symptoms: Bronchospasm, angioedema, abdominal pain,
hypotension, oedema – general/local, uticaria rash, facial flushing,
dyspnoea
Treatment: Give Chlorphenamine
Commence O2 and Salbutamol nebulizer if necessary
If severe hypotension give Adrenaline
3. Bacterial contamination
Signs and symptoms: Pyrexia, Nausea and vomiting, uticarial rash,
facial flushing, tachycardia, hypo/hypertension
Treatment: Oxygen, Fluid support (IV) Commence broad spectrum
antibiotics
4.
TRALI(Transfusion Related Acute Lung Injury)
Signs and symptoms: Dyspnoea, Severe SOB
Treatment: Give 100% oxygen and ventilate if hypoxic
5. Fluid overload
Signs and symptoms: Pulmonary oedema, SOB, hypertension,
generalised oedema
Treatment: Give furosemide and reduce fluids
Created by dagacy
38
Delayed Reaction
More subtle, typically occur in 5 -14 days following transfusion or as early
as 2-3 days following a re-challenge. This reaction is usually found by the
BTL
Signs
Unexplained drop in haemoglobin
Possible rise in billirubin/jaundice
There are few patient symptoms related to flu like symptoms; tired,
shivery, flushing and perhaps fever.
Created by dagacy
39
Appendix 3:
Final check with patient present
Individual checking by two authorised persons
Step 1: Check 14
digit donation
number to Unit
Identification
Label, if they
match
Step 2: Check patient
information on Unit to
Identification Label
to patient’s ID
wristband, if the
information matches
Jane Doe
22/03/56
Hosp No2658970
Step3: Transfuse
Traceability
‘Final Fate of every unit needs
to be recorded by the BTLab’
GO54 708 151 567 E
2658970
Doe
Jane
N1
22/03/1956
A Rh(D) pos
GO54 708 151 567 E
Comp
2658970
A Rh(D) pos
GO54 708 151 567 E
Packed red cells
2658970
b
R
La
to
n
r
etu
Created by dagacy
Section 1: Remains attached
Section
1: Remains
attached
to the Blood
Bag
to the Blood Bag
Section
Section2:2:After
Afterfinal
final bedside
bedside
check
checkand
andcommencing
commencing
transfusion- -sign,
sign,fill
fill in
in start
start
transfusion
time&&date,
date,then
thenaffix
affix peel
peel of
of
time
labeltotoPatient’s
Patient’sTR
TR
label
Section
is section of
Section3:3:It This
the Identification
must
recommended
thattag
this
be
torn
off,
as
soon
as
the
section of the CT be torn
off,
begins
& returned to
asinfusion
soon as
the infusion
the BT Lab via the collection
begins.
folder
Remember
to sign, print
Remember
to sign,
name,
date and
time print
before
name, in
date
and timefolder
placing
collection
40
Emergency O RhD negative blood
Emergency O negative red cells
Fill in patient’s hospital number
Fill in patient’s: Hospital number
DoB
Full name
John Doe, 3767432, 08/09/1980
John Doe
08/09/1980
3767432
Created by dagacy
Complete with
patient details
41
MCQ
1. How would you identify the patient? Choose the correct answers
a)
b)
c)
d)
Ask the patient to state their full name and date of birth (DoB)
Look at the patient’s wristband
Ask another nurse
Look at the patient’s medical notes
2. If the patient’s DoB is incorrect. Choose one correct answer
a)
b)
c)
d)
Begin the transfusion and then inform the BTL
Put the unit in the ward fridge and then ring the BTL for instructions.
Return the unit to the blood bank immediately
Transfuse and document the discrepancy
3. Choose one correct answer. Red cells are transfused to…
a)
b)
c)
d)
Increase the circulating volume
Stop bleeding
Treat anaemia
Treat infections
4. The maximum time for a red cell transfusion is…
a)
b)
c)
d)
60 minutes
2 hours
3 hours
4 hours
5. FFP is usually transfused over…
a)
b)
c)
d)
3 hours
30 minutes
60 minutes
10 minutes
6. Platelets are usually transfused over….
a)
b)
c)
d)
60 minutes
2 hours
3 hours
30 minutes
7. The above components can be prescribed …
a) Over the telephone
b) Written prescription
c) During the ward round, verbally
Created by dagacy
42
8. If you know the patient they need not wear an ID wristband during the
transfusion. True or False
9. The final check before transfusion can take place in the treatment room.
True or False
10. Blood components can be administered through a…..
a)
b)
c)
d)
Fluid giving set
All red blood cells must be given through a blood warmer
Blood component giving set
Through a blood component giving set and a pump
11. Before transfusing a blood component it is important to….
a)
b)
c)
d)
Weigh the unit first
Weigh the patient before the transfusion
Check the unit for leaks, discolouration and date of expiry
Check that the unit has a bar-coded label
12. All prescriptions must include a transfusion rate and doctors signature.
True or False
13. Daniel’s blood group is A Rh D positive and he requires a platelet
transfusion. Choose a suitable/compatible component.
a)
b)
c)
d)
A Rh D negative
B Rh D positive
O Rh D positive
AB Rh D negative
14. It is possible to transfuse Rh D negative components to Rh D positive
patients. True or False
Created by dagacy
43
Glossary
Blood component: Red Cells, Platelets, Fresh Frozen Plasma,
Cryoprecipitate, White Cells
Blood Product: Any therapeutic product derived from human whole blood or
plasma donations
Cross-match: Laboratory test used to find compatible or suitable allogenic
blood (donor blood) for transfusion to a patient/recipient.
Febrile non-haemolytic: Fever or rigors during red cell or platelet transfusion
affect 1-2% of recipients, mainly multi-transfused or previously pregnant
patients, although these reactions are probably less frequent with
leucodepleted components. Features are fever (>1°C above baseline) usually
with shivering and general discomfort occurring towards the end of the
transfusion or up to 2 hours after it has been completed. Most febrile reactions
can be managed by slowing or stopping the transfusion and giving an
antipyretic e.g., paracetamol (not aspirin). These reactions are unpleasant but
not life-threatening.
Group & Screen: Laboratory test to identify the patient’s ABO and Rh D
blood group and screen for antibodies.
Haemoglobin count: Laboratory diagnostic test to identify the amount of
Haemoglobin in a person’s blood.
Satellite Blood Bank; A refrigerator which stores cross-matched blood but
is
situated away from the BT laboratory e.g. by theatres or in the
Emergency Deprtment.
Serious Adverse Events; Any untoward occurrence associated with the
collection, testing, processing, storage and distribution of blood and blood
components that might lead to the death or life threatening, disabling or
incapacitating conditions for patients or which results in, or prolongs,
hospitalisation or morbidity.
Serious Adverse Reactions; Any unintended response in a donor or
recipient that is associated with the collection, testing, processing, storage
and distribution of blood and blood components that is fatal, life threatening,
disabling or incapacitating conditions for patients or which results in, or
prolongs, hospitalisation or morbidity.
SHOT is a voluntary, confidential, anonymous reporting scheme for the
notification of serious sequelae of transfusion of blood components or blood
products.
Created by dagacy
44
Traceability; means the ability to trace each individual unit of blood or blood
component derived thereof from the donor to its final destination, whether this
is a recipient, a manufacturer of medicinal products or disposal, and vice
versa
Transfusion Transmitted Infection (TTI); Blood borne infections e.g. Human
Immunodeficiency Virus (HIV), Hepatitis C & B, Syphillis etc. that can be
transmitted from donor to recipient via a blood transfusion.
variant Creutzfeldt-Jakob Disease (vCJD); A fatal disease which may be
transmissible through prions transferred during transfusion of blood products
from an infected donor. It is believed to be linked to Bovine Spongiform
Encephalopathy (BSE) and affects much younger adults than CreutzfeldtJakob Disease (CJD)
1. BSE: A neurological disease of cattle which is generally thought to
have caused the incidence of vCJD in humans
2. CJD: A neurological disease that targets the brain which can be fatal
Created by dagacy
45
References
Serious Hazards of Transfusion (SHOT) (2007) 10th Annual Report,
Manchester.
www.shotuk.org
Southampton University Hospitals Trust Blood Transfusion Policy, 2006
Department of Health (2005) The Blood Safety and Quality Regulation (No 50)
www.opsi.gov.uk
Serious Hazards of Transfusion (SHOT) (2005) 8th Annual Report,
Manchester.
www.shotuk.org
Handbook of Transfusion Medicine, Ed DBL McClelland, 4th Edition, United
Kingdom Blood Services
www.transfusionguidelines.org.uk
British Committee for Standards in Haematology (1999) ‘Guidelines for the
administration of blood and blood components and the management of the
transfused patient’, Transfusion Medicine, 9 (3) pp 227-238.
www.bcshguidelines.com
British Committee for Standards in Haematology (2004) ‘Transfusion
guidelines for neonates and older children.
www.bcshguidelines.com
Department of Health (2001) Essence of care, HMSO, London.
Nursing and Midwifery Council (2002) The Code of Professional Conduct.
Created by dagacy
46