BLOOD COMPONENTS WHAT DO YOU NEED TO KNOW?

1. BLOOD COMPONENTSWHAT DO YOU NEED TO KNOW? Janine Carnell Transfusion Nurse Consultant Eastern Health Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health

2. Myths and Legends • Egyptian princes, knights and royalty bathed in it – resuscitate the sick and rejuvenate old and incapacitated • Warriors, hunters and Romans drank it – from dying gladiators (such blood was especially beneficial since the athletes were strong and brave) • Used as a sacrifice to the Gods by ancient American and Mexican Indians. • In England, blood from newly executed criminals was a curative (prescription required).

3. BLOOD TRANSFUSION HISTORY • In 1667,Dr. Jean-Baptiste Denys (physician to King Louis XIV of France) transfused the blood of a sheep into a 15y.o. boy who survived the transfusion (small amount) • The first successful human-to-human blood transfusion • 1818-1829 by eminent British obstetrician and physiologist James Blundell (PPH: husband to wife). 5 out of 10 of his subsequent transfusions were successful. • Many other examples • Karl Landsteiner discovered A, B + C (O) groups 1901. • 4th major group (AB) reported by Decastello and Sturli in 1902. • Around 1937, discovery of the Rhesus blood group system – which was found to be the cause of the majority of transfusion reactions up to that time • Today, to meet the annual needs of patients, Victoria collects approx: 250,000 blood donations, 78,000 plasma donations and 9,000 platelet donations

4. Who uses blood?

5. Red Cells (>200mls) • Treatment of clinically significant anaemia with symptomatic deficit of oxygen carrying capacity • Replacement of traumatic or surgical blood loss • Paediatric (25-100mls) – infants, young children and intrauterine transfusion (RCH) • Special Red cells - i.e. irradiated, washed, fully phenotyped, CMV negative, whole blood, directed donations, autologous blood • Use blood of identical ABO and Rh(D) type whenever possible. • In an emergency situation, Group O Rh(D) Negative blood should be given while the patient's blood group is being established. • One unit of red cells raises the haemoglobin concentration in an average sized adult by approximately 10 g/L. • Red cells are filtered to remove most leucocytes and may be resuspended in other additives to prolong storage. • Although important, the patient’s haemoglobin level should not be the sole deciding factor for giving red cells.

6. Consider • RBC transfusion should not be dictated by a Hb concentration alone, but should also be based on assessment of the patient’s clinical status. • Where indicated, transfusion of a single unit of RBC followed by clinical reassessment is appropriate.

7. HAEMOGLOBINCONSIDERATIONS • <70 g/LLower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available. • 70–100 g/LLikely to be appropriate during surgery associated with major blood loss or if there are signs or symptoms of impaired oxygen transport. • >80 g/LMay be appropriate to control anaemia-related symptoms in a patient on a chronic transfusion regimen or during marrow suppressive therapy. • >100 g/LNot likely to be appropriate unless there are specific indications.

8. Platelets • Therapeutic – Bleeding due to decreased platelet production or functionally abnormal platelets • Prophylaxis – rapidly falling or low platelet counts • <10 x 109 /L secondary to cancer or chemotherapy or bone marrow failure without risk factors • <20 x 109 /L in bone marrow failure in the presence of additional risk factors (e.g., fever, antibiotic or evidence of systemic haemostatic failure) • Maintain >50 x 109 /L for most surgical procedures; and >100 x 109 /L for surgeries with high risk of bleeding (e.g., ocular or neurosurgery) • Apheresis (100-400mls) – single donor • Pooled (>160mls) – 4 donations • Paediatric (40-60mls) – infants, as above • One standard dose (1 pack apheresis or 1 pooled) would be expected to increase the platelet count of a 70 kg adult by approx 20–40 x 109 /L NB. ALL platelets from ARCBS in Victoria are universally leucodepleted and irradiated. Check labelling

9. FFP (Fresh Frozen Plasma) • Patients with coagulopathy who are bleeding when specific therapy (such as Vitamin K or factor concentrates are unavailable) • To replace labile plasma coagulation factors during massive transfusion, cardiac bypass, liver disease or acute disseminated intravascular coagulation in the presence of bleeding and abnormal coagulation • Double split (250-334mls) • Triple Split (250-310mls) • Paediatric (~60-80mls) is separated from a single unit of whole blood and then divided into 4 packs. Reduce donor exposure and minimise product wastage • Volume depends on clinical situation, patient size and laboratory tests. General guide is 10 -15mL/Kg per dose. • Given in addition to Vit.K in warfarin overdose • Warfarin Reversal Guidelines (Vit.K, PTX, FFP)

10. Cryoprecipitate Cryo (10-40mls) • Treatment of fibrinogen deficiency with clinical bleeding, an invasive procedure, trauma or disseminated intravascular coagulation • Massive transfusion • Apheresis (60mls) 1 unit of cryoprecipitate apheresis is approximately equivalent to 2 units of cryoprecipitate derived from whole blood • A common dose for fibrinogen replacement is 30–40 mL cryoprecipitate for each 10 kg patient body weight (~5 – 10 units) • Prepared by thawing FFP and recovering the precipitate. The cold-insoluble precipitate is refrozen. • It contains most of the factor VIII, fibrinogen, factor XIII, von Willebrand factor and fibronectin from FFP.

11. Blood Management GuidelinesNHMRC, ASBT, NBA6 Modules Module 2: Perioperative • Minimise requirement • Promote appropriate use Identify high risk patients, and develop a specific management plan ahead of time Clinical Guidance • Effect of anaemia on outcomes • Effect of blood transfusion on outcomes • Cessation of medications that affect haemostasis • Peri-operatvie strategies to minimise blood loss • Prevent hypothermia, positioning, deliberate hypotension, cell salvage • Triggers for transfusion – coagulation parameters • Anaesthesia and Patient Blood Management

12. BLOOD MANAGEMENT GUIDELINES • Pre-Op management • Anaemia – optimise Hb and iron stores • Haemostasis management – warfarin, aspirin, NSAIDs considerations • Blood Conservation Strategies • Pre-op Pre-operative Autologous Donation (PAD) • Intra-op Acute Normovolaemic Haemodilution (ANH) Cell Salvage • Post-op Cell Salvage • Appropriate transfusion practice Transfuse in accordance with clinical practice guidelines

13. INDICATIONS FOR BLOOD IN THEATRE • Elective surgery– well planned • Emergency – chaotic • Acute blood loss • Obstetric – blood loss unpredictable (intra-op, post-op) • Hb levels and surgery • Levels 70-100g/L – transfusion likely to be appropriate if major blood loss or S/S of impaired O2 transport • Bleeding disorders (acquired/congenital) – liver disease, aspirin-induced platelet dysfunction, DIC, thrombocytopaenia, haemophilia • Anti-coagulated patient – be aware • MBOS – Maximum Blood Order Schedule – local hospital policy e.g. Arthroscopy (nil), Caesarean (G+S), Open Prostatectomy (2units)

14. Risks in Theatre • Checking remains VITAL • Emergency or Elective • Crossmatched or Emergency Uncrossmatched • Unconscious or Unidentified patient • Local hospital policy • Remote or Satellite fridge • Must have a detailed register of products in and out • Audit trail between Blood Bank and Theatre • Alarmed, monitored, maintenance schedule • Rapid access • Protection from public • Multiple theatres – multiple units in fridge Source - Toonpool.com

15. CURRENT RISKSTRANSFUSION TRANSMITTED INFECTION • “Australia has one of the safest blood supplies in the world in terms of viral safety.” – ARCBS Source – ARCBS website July 2012

16. Informed Consent • Informed consent for transfusion means a documented dialogue has occurred between the patient and a prescriber : • The reason for the proposed blood product transfusion. • The nature of the proposed blood product transfusion – what is involved • The risks and benefits of the blood product as well as the risks or consequences of not receiving the product. • The availability and appropriateness of any other blood management strategies. • An opportunity to ask questions. • Use of a competent interpreter when the patient is not fluent in English. • Use of written information or diagrams where appropriate. • Be aware of local hospital policy • Specific consent form? Generic Consent form? Request slip? Progress Notes? • Who signs? Doctor? Patient? Witness? • Refusal?

17. DOCUMENTATION – BLOOD TRANSFUSION • Variation in forms and requirements across Health Services • Know hospital policy • Request slip • Patient details, components required, urgency, modifications, indications, prescribers and collectors signatures… • Blood release form • Where, what, who… • IV orders/Prescription for blood – specific, detailed • Date, timing, terminology, special requirements, urgency… • Compatibility report form • Details of component, patient ID, crossmatch compatibility… • Observation charts, Fluid Balance Charts, Progress Notes • Specific blood obs, what is documented in notes… • Adverse event form / Transfusion Report Form • Reactions, errors, also consider Hospital incident reporting systems • Consent requirements

18. EQUIPMENT – FILTERS • Stored blood contains blood clots and particles that are potentially fatal to the recipient. • This can cause pulmonary complications and death • It is essential that there is an integral in-line filter in the giving set to administer a blood product • This filter (170-200 micron) removes clots and small clumps of debris that may form during collection and storage. • All red cells and platelets issued by the Blood Service are leucocyte depleted • Therefore additional bedside leucocyte depletion filters are NOT required. • Microaggregate filters (pore size 20-40 microns) are intended to remove microscopic debris from stored red blood cells. • There is no evidence from controlled trials that they offer clinical benefit and their use is not generally recommended.

19. EQUIPMENT – IV LINES • IV Lines • Must contain an inline filter (mesh in/above the drip chamber) • Primed with normal saline or the blood component • Must not be piggy-backed onto another line • Attachment to extension tubing on an IV cannula/multi-lumen venous access device is acceptable • How many units can be put through a single IV line? • Any number provided the flow remains adequate – if the line becomes clogged – change it • Usually the entire transfusion episode • Must be changed when transfusion is complete/every 12 hours if not yet complete • reduce the risk of bacterial growth occurring Generally speaking – if there is mesh in/above the drip chamber – this is an inline blood filter and you DO NOT need any additional filter

20. IV FLUIDS Compatible Incompatible • N/Saline • 4% albumin • Plasma protein fractions • ABO compatible plasma • Morphine,or Ketamine or Pethidine (diluted in normal saline) • Gelofusine • Calcium containing solutions (e.g. Hartmann’s, Haemaccel) – may cause clotting in line • 5% dextrose – may cause red cells to haemolyse • Most medications – need to flush the line before and after administration The only IV fluid universally compatible with blood components is 0.9% sodium chloride (normal saline)

21. EQUIPMENTPUMPS, PRESSURE DEVICES, RAPID INFUSERS, SYRINGE DRIVERS • Pumps • may be used to prevent problems with slow flow rates or clogging • paediatric patients, or those at risk of fluid overload • PICC, CVAD • monitored hourly throughout the infusion to ensure that expected volume is delivered • Pressure Devices and Rapid Infusers • used with large volumes of red cells in the setting of critical bleeding • usually also warm the red cells • Must be monitored at all times during use • Syringe Drivers • Paediatric use –need to ensure that blood passes through 170-200micron filter • Continuous transfusion of coagulation factors

22. EquipmentBlood Warmers • Not usually required in routine transfusions • The use of a blood warmer is often advised for: • Large volume rapid transfusions of; • >50 mL/kg/hour in adults or • >15 mL/kg/hour in children • Exchange transfusions • Plasma exchange for therapeutic apheresis in adults. • Intrauterine transfusions, at the discretion of the feto-maternal specialist • Patients with clinically significant cold agglutinins • Red cells must not be warmed above the set point temperature of the approved device, commonly 41°C. • DO NOT warm blood in hot water, microwave, radiators or under your arms!

23. Pre-transfusion check • The last place we can make sure we are giving the right blood to the right patient • Consequences of failure in checking process: • Right Blood – lucky it arrived for the right patient • Wrong blood – compatible – good luck • Wrong component – (e.g. CMV negative, irradiated etc.. ) Puts the patient at risk of adverse event – sometimes this can be delayed • Wrong blood – incompatible – this can result in severe transfusion reactions and even death

24. PATIENT IDENTIFICATION • Local hospital policy • No ID Band = No Blood? • In emergency situations, a process should be in place for cases where a patient is unable to be identified • Hospitals must have a written policy on the requirements for patient identification • Many health services will specify: • Patient ID – Surname, given name, DOB, UR number • Additional identifiers e.g. gender, address, Medicare number • Neonates – 2 ID bands? • Unconfirmed identity – name changes – “unknown female” • 2 approved staff members must carry out the Patient ID check prior to blood transfusion

25. Pre-Transfusion Check • If ANY discrepancy – DO NOT transfuse • All done at the BEDSIDE • Blood Bag • Patient ID • Documentation

26. Observations • Temperature, pulse, respiration rate and blood pressure MUST be measured and recorded : • Prior to the start of each individual blood component pack administered • 15 minutes after commencing administration of each blood component pack • When administration of each blood component pack is completed • There is no consensus on subsequent frequency of routine vital sign measurement during transfusion, however many institutions stipulate hourly measurements, after the initial 15 minute period, until completion of the transfusion. • Regular visual observation throughout the transfusion is essential • Blood Pressure, Temperature, Pulse, Respiratory Rate • Baseline • 15 minutes • Hourly from commencement time • Stop time Remember – most transfusion reactions occur within the first 15 mins of transfusion

27. Transfusion Rates • The infusion rate for blood products depends on the clinical context, age and cardiac status of the patient. • In stable, non-bleeding adult patients typical administration durations are: • Red cells 60-180 minutes per unit • Platelets 15-30 minutes per standard adult dose • FFP 30 minutes per unit (i.e. 10-20mL/kg/hr) • Cryoprecipitate 30-60 minutes per standard adult dose (i.e. 10-20mL/kg/hr). • Note – in an emergency you are limited only by the size of the cannula

28. Time limits • Commence transfusion within 30 minutes of arrival from Blood Bank • If returned to the BB within 30mins it can be returned to the fridge and then released to any other patient as required. • Once it has been at room temp for >30mins it cannot then be used for any other patient – you then have up to 4 hrs MAXIMUM to complete the transfusion • Transfusion must be complete within 4 hours • Risk of bacterial proliferation greatly increases when unit is at room temp for >4 hours

29. Transfusion Reactions • Local hospital policy • Recognise, React and Report • Most common adverse reaction = fever • Mild Reactions include: • Fever, rash, • Moderate to Severe reactions include: • Fever, hypotension/shock OR hypertension, tachycardia, tachypnoea, wheeze, stridor, rigors or chills, nausea, vomiting or pain (local, chest, back) • Reporting requirements • Flow chart to follow? • Report form to complete? • Investigations required? • Documentation?

30. Transfusion Reaction in an unconscious patient • May occur after only 5-10 ml • In a rapid emergency transfusion – signs may only be evident after several units • Extra care must be taken in the unconscious patient to monitor and react to changes in vital signs Possible Signs of a Severe Adverse Reaction to Transfusion in an Unconscious Patient • Temperature rise more than 10C • Pink or red urine (hemoglobinuria) • Increased operative bleeding • Hypotension • Reduced urine output • Tachycardia or bradycardia

31. Nursing management • Recognise • that signs and symptoms may be due to the transfusion • React • immediately STOP transfusion • assess and manage patient, follow policy • review documentation (in particular check the pt’s ID band against blood bag and compatibility report form) • Report • to HMO and Blood Bank Document: (local hospital policy) • Transfusion Report Form and/or Incident report • Progress notes • Investigations – pathology slip

32. TRANSFUSION REACTION FLOW CHART

33. Many other resources are available

34. RESOURCES / ACRONYMS • Australian Red Cross Blood Service (ARCBS) http://www.transfusion.com.au/ • Australian and New Zealand Society of Blood Transfusion (ANZSBT) http://www.anzsbt.org.au/ • Australasian Society of Blood Transfusion (ASBT) • National Blood Authority (NBA) http://www.nba.gov.au/ • National Health and Medical Research Council (NHMRC) http://www.nhmrc.gov.au/guidelines/publications/cp78 • Blood Matters Program – Department of Health http://www.health.vic.gov.au/bloodmatters/ • Local hospital policies

35. QUESTIONS? Janine Carnell Transfusion Nurse Consultant Eastern Health Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health