Transfusions

Question 1

What is SHOT?

Answer 1

SHOT (Serious Hazards of Transfusion Reporting Scheme) is a reporting scheme that collects data about serious adverse events & reactions of transfusion and makes recommendations to improve transfusion safety

Question 2

What is the biggest risk of transfusions?

Answer 2

Receiving incorrect component (often due to human error)

*Common misconception that infection is biggest risk but risk of infection is actually very small

Question 3

Remind yourself of different ABO blood groups and the antibodies each has

Answer 3

Question 4

Which blood should you give to patients (in terms of their ABO group)?

Answer 4

• Blood of their own ABO type
• But can give group O to all pts

Question 5

What % of the population are D positive?

What type of blood can D positive receive?

What type of blood can D negative receive?

Answer 5

• 85% D positive, 15% D negative
• D positive can receive D positive or D negative blood
• D negative can only receive D negative blood

Question 6

What is meant by a forward group check?

What is meant by a reverse group check?

Answer 6

• Forward group check is checking cells for presence of ABO antigens
• Reverse check is checking plasma for presence of anti-A and anti-B antibodies

Question 7

Giving wrong ABO group (even just a few ml) can trigger massive immune response leading to shock & DIC; patient may die from circulatory collapse, severe bleeding or renal failure within minutes or hours. True or false?

Answer 7

True

Question 8

For each of the following ‘special requirements’ for blood state some example situations in which they are used

• CMV negative
• Irradiated
• Blood of specified age
• Paedipacks

Answer 8

• CMV negative: all components for neonates up to 28 days post expected delivery date should be CMV negative
• Irradiated: used to destroy any T lymphocytes remaining in blood donation; these may cause graft-versus-host disease in vulnerable patients. Examples of situations in which irradiated blood should be used (according to BSH): intrauterine transfusion, neonatal exchange transfusion, top up transfusion after IUT, proven or suspected immunodeficiency
• Blood of specified age: for example blood of less than 5/7/10 days old may be required if concerns about potassium content in older samples
• Paedipacks: one adult unit is divided between 4-8 aliquots. Several aliquots allocated to one child to allow sequential transfusions form same donor, reducing donor exposure

Question 9

What blood can you use in an emergency (where you don’t have time to wait to find out blood group, crossmatch etc….)?

Answer 9

O D negative blood

Question 10

For RBC’s, state:

• Temp they must be stored at
• Shelf-life
• Time within which they must be transfused
• What to do if you don’t end up using them

Answer 10

• 2-6 degrees in alarmed fridge with temperature recorder
• 35 days (unless irradiated)
• Use within 4hrs of removal from controlled temperature
• Return to lab with clear documentation confirming length of time out of temperature controlled storage (may be able to be used for someone else)

Question 11

For platelets, state:

• Temperature stored at
• Shelf-life
• What to do if don’t use

Answer 11

• Platelets stored at 20-24 degrees in an agitator
• Shelf life of 5-7 days
• If unused return to lab as they may be reissued

Question 12

For FFP and cryoprecipitate, state:

• Temperature stored at
• How long can be stored for
• What to do before you transfuse
• What to do if unused

Answer 12

• -25 degrees
• Stored for up to 3yrs
• Must be thawed at 37degrees for ~15 minutes before transfusion… then transfuse ASAP (transfusion must be completed within 4hrs of thawing time)
• If unused send back to lab (cannot be refrozen but may be able to be used for another pt within defined period of time)

Question 13

For each of the following blood products, state what they contain:

• Packed red cells
• Platelets
• FFP
• Cryoprecipitate
• Prothrombin complex concentrate

Answer 13

• Packed red cells = red blood cells
• Platelets = platelets
• FFP = clotting factors
• Cyroprecipitate = fibrinogen, VWF, factor VIII and fibronectin
• Prothrombin complex concentrate = factor II, VII, IX, X (vit K dependent clotting factors)

Question 14

For each of the following blood products state when they would be used:

• Packed red cells
• Platelets
• FFP
• Cryoprecipitate
• Prothrombin complex concentrate

*NOTE: idea is to be able to work it out based on knowing what each one contains

Answer 14

Packed red cells

• Acute blood loss
• Chronic anaemia (<70g/L or <100g/L in CVD) or symptomatic

Platelets

• Haemorrhagic shock
• Thromboctyopenia <20x10⁹
• Bleeding with thrombocytopenia
• Pre-op platelets <50x10⁹

FFP

• DIC
• Haemorrhage secondary to liver disease
• All massive haemorrhages commonly after 2nd unit of packed red cells

Cyroprecipitate

• DIC with fibrinogen <1g/L
• Von Willebrands disease
• Massive haemorrhage

Prothrombin complex concentrate

• Warfarin reversal

Question 15

What details should be included on transfusion request form, consider:

• Patient details
• Clinical details

Answer 15

Patient Details

• First name
• Last name
• Middle name (check local policy)
• Unique identification number
• Location of patient
• Gender
• Patients address (check local policy)

Clinical Details

• Number & type of component required
• Urgency of request
• Location of pt
• Blood group antibodies if known
• Previous transfusion history
• Any special requirements
• Date and Time required
• Your name & signature

Question 16

Outline the 5 steps involved in blood product transfusions

Answer 16

• Collect initial blood sample
• Prescribe blood transfusion
• Check blood transfusion
• Administer blood transfusion
• Monitoring the patient during transfusion

Question 17

Outline how to collect initial blood sample in blood transfusions

Answer 17

• Wash hands, don PPE
• Ask pt to state name & DOB and compare this to identity band
• Check pt’s identity band details against blood request form checking for first name, last name, middle name (some trusts), unique pt identification number, gender (some trusts), address (some trusts)
• Perform venepuncture
• Immediately label bottle at patients bedside
• Complete associated blood transfusion form ensuring:
  
  • All pt details are correct (name, DOB, middle name (some trusts), unique identification number, location of patient, gender (some trusts), patient’s address (some trusts), location of patient
  • Consultant in charge of patient
  • Document number & type of blood products required
  • Document any special requirements
  • Clinical indication for transfusion
  • Transfusion history & atypical antibodies if known
  • Urgency of request/time & date blood component is required
  • Time & date of request
  • Your name & signature

NOTE: if a sample is urgent you must phone/alert laboratory also

Question 18

Outline how to prescribe blood transfusions

Answer 18

• In most cases, written on fluids chart (but may differ e.g. UHL have blood transfusion prescribing chart)
• Each unit must be prescribed separately on it’s own line
• Include time & date of infusion, clinical indication

Question 19

Outline what checks must be done prior to transfusing blood product (i.e. by bedside before you administer)

Answer 19

• Have a nurse or doctor check with you
• Ask pt to confirm name & DOB and check this against identity band
• Check identity band against blood compatibility report to ensure patient details match
• Ensure baseline observations have been recorded
• Check the blood product to ensure:
  
  • It’s correct product (and is is compatible)
  • Donation number on label matches that on the bag
  • Product meets any special requirements
  • Expiry date & time of the product
  • Inspect for signs of damage, tampering, leaks, discolouration, clots

Question 20

Outline how to administer blood transfusion

Answer 20

• Must use CE marked transfusion set (has integral mesh to remove microaggregates)
• Prime line with some blood (not NaCl) to expel any air
• Attach giving set to cannula (aseptic technique)
• Set time blood should be transfused over
• Ensure:
  
  • No other medications or fluids are administered through the line
  • Platelets are not administered through a set that was previously used for packed red cells (causes aggregation)
  • Change administration set every 12hrs for ongoing transfusion
• Document date & time transfusion was started and ensure you both sign to confirm all checks where carried out

Question 21

Outline what monitoring must be done during a transfusion

Answer 21

• Baseline/before transfusion (within 60mins of start time)
• 15mins
• 30 mins
• Can then perform on hourly basis
• End of transfusion

Question 22

State some complications of packed red cell transfusions (4)

Answer 22

• Clotting abnormalities: due to dilution effect hence we often give FFP and platelets concurrently in pts having >4 units of PRC
• Electrolyte abnormalities:
  
  • ​Hypocalcaemia: chelation of calcium by calcium binding agent in preservatives
  • Hyperkalaemia: partial haemolysis of RCCs and release of intracellular K+
• Hypothermia: blood products thawed and kept cool so may not be up to body temp by time of transfusion

Question 23

State 7 ACUTE transfusion related complications (within 24hrs)

Answer 23

• Acute haemolytic reaction
• Transfusion associated circulatory overload (TACO)
• Transfusion related lung injury (TRALI)
• Mild allergic reaction e.g. itching
• Non-haemolytic febrile reaction
• Anaphylaxis
• Infective/bacterial shock

Think of as:

• Immune mediated: acute haemolytic reaction, TRALI, anaphylaxis, mild allergic reaction
• Non-immune mediated: bacterial infection/shock, TACO

Question 24

For acute haemolytic reaction state:

• What it is
• Presentation
• What test confirms diagnosis
• Managment

Answer 24

• Serious reaction due to blood incompatibility (usuallly due to ABO incompatibility). Donor red blood cells destroyed by recipients antibodies
• Presentation:
  
  • Urticaria
  • Hypotension
  • Fever
  • Haemoglobinuria (red urine)
  • Low Hb
  • Low haptoglobin
  • High LDH
  • High bilirubin
• Positive direct antiglobulin test= CONFIRMS
• Management:
  
  • Stop transfusion
  • Supportive measures
  • Inform blood bank

Question 25

For transfusion associated circulatory overload, discuss: * What it is * How it presents * Management

Answer 25

* Fluid overload as a result of infusion. Occurs in pts who are often already fluid overloaded * Presentation: * Dyspnoea * Features of fluid overload * Management: * Urgent CXR * Oxygen * Diuretics *\*can give 20mg furosemide prophylactically in those at risk*

Question 26

For transfusion related acute lung injury, discuss: * What it is * How it presents * Management

Answer 26

* Non-cardiogenic cause of pulmonary oedema. Pathophysiology not fully understood but donor antibodies against recipient neutrophil antigens and human leukocyte antigens have been implicated. * Presentation: * Sudden dyspnoea * Severe hypoxaemia * Hypotension * Fever * Features of pulmonary oedema on examination * Management: * High flow oxygen * Urgent CXR * Specialist & intensive care input * Usually resolves after 48-96hrs with specialist supportive care

Question 27

Compare TACO and TRALI

Answer 27

Question 28

How would you treat the following acute complications of blood product transfusions: * Mild allergic reaction * Non-haemolytic febrile reaction * Anaphylaxis * Infective/bacterial shock

Answer 28

* **Mild allergic reaction** * Stop transfusion, seek medical advice & assess pt * Re-check blood products are correct * Antihistamines e.g. chlorphenamine * Continue transfusion under close observation * **Non-haemolytic febrile reaction** * Stop transfusion, seek medical advice & assess pt * Re-check blood products are correct * Antihistamines e.g. chlorphenamine * Antipyretics e.g. paracetamol * May restart at slow rate with close observation * **Anaphylaxis** * **​**Stop transfusion * Usual anaphylaxis management * **Infective/bacterial shock** * **​**Stop transfusion * Basic resuscitation measures * Blood cultures * IV abx *IN ALL SITUATIONS CONSULT A SENIOR*

Question 29

State some potential delayed complications of blood product transfusions

Answer 29

* **Delayed haemolytic transfusion reaction:** caused by antibodies to antigens such a rhesus or kidd. Occurs 3-14 days post-transfusion. Present with sudden drop Hb, fever, jaundice, haemoglobinuria * **Infection** with blood bourne disease e.g. hepatitis b & C, HIV, syphilis, malaria, vCJD * **Graft vs host disease:** complication due to receipt of transplanted tissue from a genetically different individual. White cells in donated tissue recognise the recipient as foreign and attack the recipients cells. Can occur after blood transfusion due to HLA mismatch between donor and recipient. Most common if get non-irradiated blood products to immunocompromised. Presents with fever, skin involvement (ranging from maculopapular rash to toxic epidermal necrolysis), diarrhoea & vomiting * **Iron overload** most commonly in pts with repeated transfusions e.g. thalassaemia (get symptoms & signs like in hereditary haemochromatosis) * **Post-transfusion purpura:** body produces alloantibodies to the introduced platelets antigens; leads to destruction of platelets and subsequent thrombocytopenia. Usually presents 5-13 days post-transfusion

Question 30

Summary outlining how to recognise suspected acute transfusion reactions

Answer 30

Question 31

At what Hb level do we tend to transfuse?

Answer 31

**Hb \<70g/L** *\*May transfuse in other situations e.g. Hb 70-90g/L but pt symptomatic or as part of major haemorrhage protocol*

Question 32

At what platelet level do we tend to transfuse?

Answer 32

**10 x 10⁹ /L** \*\*unless severe sepsis &/or minor haemorrhage warrants a higher threshold of 20 x 109 /L