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Transfusion Guidelines Instruction Course

Transfusion Guidelines Instruction Course. Jessica Jacobson, MD Director, Blood Bank and Transfusion Medicine Bellevue Hospital Center. Requirements for Blood Bank Samples- Identification. Label must be placed immediately after drawing blood while still at the patient’s bedside .

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Transfusion Guidelines Instruction Course

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  1. Transfusion Guidelines Instruction Course Jessica Jacobson, MD Director, Blood Bank and Transfusion Medicine Bellevue Hospital Center

  2. Requirements for Blood Bank Samples- Identification • Label must be placedimmediately after drawing blood while stillatthe patient’s bedside. • Label must include at leasttwo identifiers. • These could be the name of patient; MR#; assigned name, if the patient’s name is unknown; complete date of birth. • Patient ID wrist band (bracelet) must correspond to the label on the blood sample. • Patient related data on the blood requisition slip must correspond to that of patient ID band and the sample label.

  3. Requirements for Blood Bank Samples • Blood must be collected in pink top tube after the patient has been properly identified. • Sample must be signed or initialed by the practitioner who drew the blood. • Blood sample should be transported directly to the Blood Bank

  4. Requirements for Blood Bank Samples- 2nd Stick • To ensure patient safety, one sample is not enough for any new patient. • A second sample, with a second venipuncture and patient identification procedure, must be drawn and sent to the Blood Bank for ABO and Rh confirmation. • The second sample can be drawn either by the same person within an arbitrarily chosen 10 minute interval or simultaneously by two different persons. • The second tube will have a separate accession number. 1. Type and Screen 2. ABO Rh Confirmation

  5. STAT Samples 60 minutes for Type and Screen (T&S) 10 minutes for ABO & Rh type For Rh-negative patients an additional 20 minutes is required 45 minutes for Antibody Screen STAT TAT is determined by actual incubation and centrifugation times Antibody ID may take hours or days depending upon what RBC antibody(s) Blood Bank Laboratory Testing Turn-Around-Times

  6. Anyone who is trained may pick-up blood from the Blood Bank. A transporter can not pick-up blood for multiple patients. Blood will only be issued to a given transporter for one patient at a time. For the OR multiple units can be picked-up for the same patient as long as they are transfused within 30 minutes of pick-up time Pick-up slip must be presented to the Blood Bank. The contents of this slip should include the same patient data as that on the T&S sample. If the patient’s identifier data is changed within the interval between sample drawing and blood pick-up, a new sample with appropriate labeling and computer order must be submitted to the Blood Bank. Requirements for Blood Unit Pick-Up BLOOD BANK 2 units, please

  7. Blood Bank Pick-Up Forms MDmust sign for emergency release Unless an MD is actually picking up the blood all patient data must be ADDRESSOGRAPHED Must know patient’sNAME Must know patient’sMRN Form is pale blue Emergency Release Form Pick-UpForm

  8. Emergency Release Blood • Emergency release blood implies obtaining blood which, because of urgency related time constraints, is not completely tested for a given patient. • Only physicians can pick-up emergency release blood, because only physicians are allowed to fill out an emergency release form. • Physician requesting emergency release must accurately know and record at leasttwo patient identifiers(NAME and MRN) on the emergency release form and pick-up form and sign the form with his/her MD ID#.

  9. Type O(Rh-positive or Rh-negative) uncrossmatched RBCs will be issued for patients with a yet undetermined ABO Rh type Type specific uncrossmatched RBCs will be issued when the T&S and ABO Rh Confirmation specimens have been typed Emergency Release Blood What ABO type of RBCs will be released?

  10. Requirements for Blood Unit Pick-Up • No blood may be released if above conditions are not satisfied • All blood picked-up must be directly transported to the site intended for transfusion • Any blood unit that is kept outside Blood Bank or Blood Bank monitored refrigerator for longer than30 minutescannot be returned to Blood Bank for use in another case • Transfusion must be completed within4 hoursof issuance from Blood Bank Blood transfusion should start within 30 minutes of issuance

  11. Requirements for Blood Unit Pick-Up • By law, the Blood Bank is obligated to know and document who the recipient of each unit is. • Therefore in case of a rare emergency need for blood in life threatening condition,the physician requesting emergency release of blood must at least know and documenton emergency release and pick-up formstwo patient identifiersand clearly sign with his/her MD ID#. • In this situation where type and screen sample is either not submitted or tested, the Blood Bank can only release Type O PRBCs. • If patient’s ABO type is known, ABO type specific uncrossmatched blood will be issued. NAME MRN

  12. Requirements for Blood Unit Pick-Up • The only situation where physicians can administer blood without first submitting patient identifiers is when the blood is taken directly from the ER trauma blood refrigerator. • 2 identifiers must be submitted after the patient’s ID is determined • The red blood cell units kept in the ER trauma refrigerator are Type 0 and are intendedonlyto be used in exceedingly critical situations. Universal RBC Type is O You can safely give type O red blood cells to any patient

  13. Requirements for Obtaining Plasma, Platelets, and Cryoprecipitate • For any blood product an active type & screen is required. • If the patient’s type is unknown, the Blood Bank will try to issue type AB plasma products in emergency release situations. • This is especially true for FFP and P24 since the volume is 200 ml per unit • Platelets of any ABO type may be issued depending upon inventory. • ABO type for cryoprecipitate is not particularly important due to low volume. • If the patient’s type is known, type-specific products will be given preferentially. Universal Plasma Type is AB

  14. Requirements for Administering Blood Products • In non-emergent situations a separate consent for transfusion must be obtained • No blood product may be administered before establishing agreement between the data on: • Patient’s two identifiers. • Blood unit’s data in relation to patient’s identifier data, blood unit number, ABO/Rh, expiration date/time. • Blood infusion record (crossmatch form) data in relation to patient’s identifier data, blood unit number, ABO/Rh, expiration date/time. Consent Form

  15. Requirements for Administering Blood Products • If under any circumstance, the patient is unidentifiable or there is a discrepancy between patient, unit, and blood infusion record (cross-match form), BLOOD UNITSMUSTBE RETURNEDto the Blood Bank without administering. • CALL to notify Blood Bank • DO NOT TRANSFUSE THE UNITS!

  16. Requirements for Administering Blood Products • The patient’s ID band must be attached to the patient, if they have to be removed in rare instances. • There are two ways of reattaching the patient’s ID band : • Taping it to the patient • Pinning it to the patient’s gown. • If the patient’s ID band is removed the patient’s medical record (chart)cannotbe used to identify the patient.

  17. Requirements for Administering Blood Products • In the operating room at Bellevue, one of the two individuals identifying the patient, blood unit, and the blood infusion record (crossmatch form) must be an anesthesia attending. • Outside of the OR, one of the two individuals identifying the patient, blood unit, and the blood infusion record (crossmatch form) must be a RN Mandatory Double Check

  18. Requirements for Administering Blood Products • During each blood product transfusionALLof the questions directed to the tranfusionist on the blood infusion record (Crossmatch Form) must be accurately completed. • These questions include: Date, Time, tranfusionist’s name and MD ID#, verifier’s name and MD ID#, recipients vital signs (Temp, Pulse rate, Respirations, BP) before, 15 minutes after transfusion is started and at the end of transfusion. • At the end of transfusion, date, time, volume transfused, and transfusionist’s signature must be recorded on the appropriate section of the blood infusion record (Crossmatch Form). • Signatures MUSTbe legible Crossmatch Form is a duplicate form 1st sheet is white (patient chart record) and 2nd sheet ispink(returned to Blood Bank)

  19. Red Blood Cells Hgb <7 g/dL and symptomatic anemia Hgb <9 g/dL with significant cardiovascular, cerebrovascular or respiratory Blood loss >20% (or >750 mL) refractory to fluid resuscitation Platelets Platelet count <10K per uL with or without active bleeding Platelet count <50K per uL with bleeding or undergoing major surgery Platelet count <100K per uL in patient undergoing neurosurgery or ophthalmic procedure or withintracranial hemorrhage Bleeding or immediately pre-op in patient with documented platelet dysfunction Transfusion Triggers

  20. Plasma Bleeding or immediately prior to invasive procedure and PT >17 sec, (INR >1.5) and/or aPTT >40 sec Disseminated Intravascular Coagulation (DIC) with uncontrolled bleeding Warfarin reversal (if Vitamin K contraindicated or not sufficiently rapid) TTP/HUS/HELLP syndrome / therapeutic plasma exchange Cryoprecipitate Deficiency of factors I (fibrinogen) or XIII Fibrinogen <100 mg/dL Bleeding in patients with Von Willebrand Disease when concentrates are not available Disseminated intravascular coagulation (DIC) – if bleeding and plasma not raising fibrinogen level Uremia with bleeding if not responsive to other therapy Transfusion Triggers

  21. Leukocyte reduced <5.0X106 WBC per product Decreases febrile non-hemolytic transfusion reactions Products are considered CMV safe Irradiated Required for patients at risk of developing transfusion associated GVHD Washed Available for patients who have had severe allergic transfusion reactions or have IgA-deficiency Sickle-negative RBC donor has been tested to determine if their RBCs will sickle under oxidative stress Required for patients with Sickle Cell Disease Blood Product Modifications

  22. Adults: Expected Results from Transfusion • 1 unit PRBCs should increase a patient’s Hgb by 1 g/dl or Hct by 3% • 1 single donor platelet (SDP) should increase a non-bleeding patient’s platelet count by 30-50 X109 per liter • A 1-hour post platelet count is helpful in determining if a non-bleeding patient has become refractory to platelet transfusions

  23. Plasma should be dosed at 10-15 ml/kg For adults this is roughly 4-6 units of plasma In vivo half-life of Factor VII is 2-5 hours Plasma should be given immediately pre-procedure If using plasma to replace FVII, you will need to give 10-15 ml/kg every 4-6 hours Dosing Plasma in Adults NOTE: INR of P24 and FFP is approximately 1.1-1.2

  24. Pediatrics: Expected Results from Transfusion • 10 ml/kg dose of PRBCs should increase the Hgb by 1 g/dl • 10 ml/kg dose of plasma is required to attain therapeutic levels of factors • 10 ml/kg dose of SDPs should increase the platelet count by 30-50 X109 per liter

  25. Adverse Effects of Transfusion • Infectious • Viral • Bacterial • Non-infectious • Transfusion Reactions

  26. Transfusion-Related Fatalities Reported to FDA

  27. What to do if you suspect a transfusion reaction? • Stop the transfusion! • Do not restart the transfusion • Only with urticaria may the unit be restarted after the symptoms have resolved • Report ALL suspected reactions! • Monitor and assess the patient • Notify the Blood Bank • Check to verify that the name and MRN on the blood unit matches the patient’s wrist band • Return the blood unit to the Blood Bank • Draw a post-transfusion specimen and send to Blood Bank for work-up • Provide supportive care to the patient if necessary

  28. Fever Chills Infusion site pain Change in BP Respiratory distress Hives Bleeding Clinical Symptoms of a Transfusion Reaction

  29. Infectious Risks of Transfusion

  30. What is Blood Tested For? • Lab Testing Helps Ensure Blood Safety • Tests are done on each unit of blood: • ABO blood grouping • Rh type • Red cell antibody screen • Antibodies to hepatitis B Core • Hepatitis B Surface Antigen • Antibodies to hepatitis C • Antibodies to HIV-1 • Antibodies to HIV-2 • Antibodies to HTLV I/II - (human T-Lymphotrophic Virus Types I and II) • Nucleic Acid Amplification Testing (NAT) for hepatitis C (window period is 35 days) • Nucleic Acid Amplification Testing (NAT) for HIV (window period is 9 days) • Nucleic Acid Amplification Testing (NAT) for West Nile virus • Syphilis (RPR) • Antibodies to T. cruzi (Chagas Disease)

  31. Impact of Viral Testing on Safety Volunteer Donors HBsAg HTLV 1.0 HTLV-I/II HCV 1.0 HCV/HIV NAT HIV-1 HIV-1/2 HCV 2.0 ALT WNV NAT HBsAg 3 Bacterial detection CUE Anti-HBc HCV 3.0 p24 Ag HTLV 2.0 Chagas? Babesiosis? Andromeda strain? After H. Alter

  32. Risk of Infection fromAllogeneic Blood Transfusion Infectious Risks of Blood Transfusion, Blood Bulletin, volume 4, No. 2, December 2001.

  33. Bacterial Contamination of Platelets • Major cause of transfusion related fatalities • Clusters of infection/deaths • RDP Contamination = 1:2-4,000 • SDP Contamination = 1:15,000 • Fatalities = ~ 1:40,000 (underreported) • Fatalities typically due to gram negative organisms

  34. Emerging Blood-Transmitted Infections Malaria Risk 1:4,000,000 Chagas Disease (Trypanosoma cruzi) The risk of transmission is 12-25% if transfused T. cruzi seropositive blood Babesiosis (B. microti) In Connecticut, the risk of acquiring babesiosis from a transfused unit of packed RBCs was estimated at about 0.17% Parvovirus B-19 Viremic donors 0.025% Hepatitis A Transfusion risk is 1 in 1,000,000 Variant Creutzfeld Jacob Disease (vCJD) 4 documented cases in UK 66 Patients know to have been transfused with blood from patient who later died from vCJD West Nile Virus Dengue Virus Other agents with viremic phase but not yet proven to be transfusion-transmitted Human herpes virus- 8 (HHV-8-Kaposi's sarcoma virus) Borellia (Lyme disease) Avian flu virus SARS Other Rare Transfusion Transmitted Infections

  35. Non-infectious Risks of Transfusion

  36. If not Infectious, What are the Risks? Non-Infectious Risks • Human Error and Clerical Errors • Improper Administration of the Blood Product TRALI, 7% Delayed Reaction Acute Reaction Post-Tx Purpura GVHD Infections, 2% Mis-transfusion, 66% SHOT DATA 1996-2003

  37. How common are errors? • Risk of an error occurring during transfusion of a blood component is 1:16,500 • Risk of an ABO incompatible transfusion is 1:100,000 • Risk of death as a result of an 'incorrect blood component transfused' is around 1:1,500,000

  38. Clerical Errors • Sample drawn on the wrong patient • It is vital to check the name and patient ID number every time you draw a blood sample for testing • Blood is hung on the wrong patient • It is vital to check that the name and patient ID number on the unit of blood matches that on the patient’s ID band • Labeling error • Label tubes as you draw or use them rather than batch labeling. When batching, the risk of a tube switch exists • Sample tubes must be labeled at the patient’s bedside/chairside

  39. Sample Collection Errors at BHC Identified by the Blood Bank

  40. Where do the Errors occur? SHOT Errors, 1996-2003, n=2340 Blood Center, 1.7% Prescription, sampling, request, 19.7% Unknown, >1% Other, 1% Hospital Blood Bank, 29% Collection, Administration, 48.4% Serious Hazards of Transfusion Study in UK

  41. Transfusion Errors • Transfusion errors in New York State* • Erroneous administration (1/19,000 units) • ~50% of errors occurred outside the blood bank • Blood bank errors • 29% of errors occurred in the blood bank (wrong test, issuance of wrong unit etc.) • Multiple errors • 20% involved errors at blood bank and on floor or lab • Increased scrutiny of hospital reporting by regulatory agencies * JV Linden et al (2000) Transfusion, 40: 1207

  42. Administration Errors • What can be added to a line during a transfusion? • Normal saline (0.9%) • ABO compatible plasma • 5% Albumin • Plasma protein fraction • What can never be added to a line during a transfusion? • Lactated Ringer’s solution • Contains 3 mEq/L ionized calcium • 5% Dextrose • Hypotonic sodium chloride solutions • Almost all Medications Running any of the above “never solutions” along with blood risks hemolyzing the transfused cells.

  43. Alloimmunization • Chronically transfused patients can develop antibodies to WBCs as well as RBCs • Antibodies to WBCs • Can cause febrile non-hemolytic transfusion reactions • May avoid or reduce frequency and severity by leukoreduction or pre-medication with antipyretics • Antibodies to RBCs • Can cause either acute (AHTR) or delayed hemolytic reactions (DHTR) • Can lead to hemolytic disease of the newborn • May affect the availability of blood

  44. Alloimmunization • Incidence: • RBC Antigens: 1:100 (1%) • HLA Antigens: 1:10 (10%) • Etiology: Immune response to foreign antigens on RBC, WBCs, and platelets (HLA) • Presentation: Positive blood group antibody screening test, platelet refractoriness, delayed hemolytic reaction, hemolytic disease of the newborn

  45. Impact of RBC Alloimmunization • Hemolytic Transfusion Reactions • Acute • Delayed • May make laboratory evaluation more complicated • Delay and Difficulty in providing compatible blood for transfusion • Hemolytic Disease of the Newborn

  46. Recognition of Acute Transfusion Reactions • Signs and symptoms that may be associated with any type of acute transfusion reaction • Fever • 1C (2F) increase in body temperature associated with transfusion • Shaking chills (rigors) with or without fever • Pain at the infusion site or in the chest, abdomen, or flanks • BP changes • Usually acute either hypertension or hypotension

  47. Immunologic Hemolytic Fever/Chill Urticarial Anaphylactic Non-Immunologic Hypotension associated with ACE inhibition TRALI Circulatory overload (TACO) Non-immune hemolysis Air embolus Hypocalcemia Hypothermia Types of Acute (<24 hours) Transfusion Reactions (TXRs)

  48. Hemolytic Transfusion Reactions • Acute hemolytic transfusion reactions may be either immune-mediated or nonimmune-mediated • Immune-mediated • Occur when a patient has an antibody directed against a RBC antigen on the transfused RBCs or when the plasma in the transfused blood product contains an antibody to an antigen on the patient’s own RBCs • Nonimmune-mediated • Occur when RBCs are damaged prior to transfusion • Generally results in hemoglobinemia and hemoglobinuria without significant clinical symptoms.

  49. Acute Immune-Mediated Hemolytic Transfusion Reactions • Incidence: 1:38,000 to 1:70,000 • Some reports as high as 1:25,000 transfusions • Occur during or within 24 hours after transfusion • Can be fatal • Most often due to clerical and sample identification errors • Hemolysis can be intravascular or extravascular • Intravascular • Most often due to ABO blood group mismatch

  50. Signs and Symptoms Chills Fever Hypotension Renal failure with oliguria DIC Back pain Pain along infusion vein Anxiety Pain at infusion site Hemoglobinurea Hemoglobinemia Can detect 2.5 to 5 ml RBC hemolysis Acute Immune-Mediated Hemolytic Transfusion Reactions

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