Download ORIGINAL ARTICLE Guidelines to the problems I encountered in

ORIGINAL ARTICLE
Guidelines to the problems I encountered in transfusion practice
Getting right blood to the right patient at the right time
a. Ascess the clinical need for blood & when it is required.
b. Inform the patient/relatives about the proposed transfusion treatment & put it in
record.
c. Record the indications for transfusion
d. Select the blood component & quantity required
Complete the blood request form accurately & legibly
a. Patients name, ward & bed number.
b. Component & the number of units required
c. Reason for transfusion & diagnosis.
d. Urgency of the patients requirement for transfusion.
e. The request forms should be signed by the doctor with the full name of the
doctor with rubber stamp.
f. If the patient later has a problem that could be related to transfusion ,the records
should show who ordered the blood component & why. This information is
useful for conducting an audit of transfusion practice
Obtain & correctly label a blood sample for compatibility testing.
a. Patients blood sample is placed in a sample tube correctly labeled with name
,ward, bed number & I.P number.
b. All the details on the blood sample tube should match those on the blood
request form .
c. Send the blood request form & the blood sample for compatibility testing.
Bedside transfusion practices –
a. Check – patients identity on the blood / component bag & its documents. the issued blood
unit is accompanied by – crossmatch form, consent form & transfusion reaction form.
b. The blood bag should always be inspected for signs of deterioration on arrival in the ward or
OT before transfusion if it was not used immediately.
Check for - discolouration or signs of any leakage
- Any signs of haemolysis (check if the plasma is pink )
- Any clots
DO NOT ADMINISTER BLOOD /ITS COMPONENTS –
-
If the blood bag appears abnormal /damaged.
Blood has been or may have been out of the refrigerator for more than
30 minutes.
Do not refrigerate the platelets.
Final patient identity check –
- Should be undertaken at the patient’s bedside immediately before
commencing the transfusion.
- It should be undertaken by two people – registered nurse & doctor.
- Presence of the doctor is mandatory when the blood transfusion is started.
-
Check the details on the compatibility label & the expiry date on the blood bag
-
The doctor will ensure that there are no discrepancies between ABO & Rh on
blood bag & compatibility label.
-
No discrepancies in the donation number on blood bag & documents
accompanying it..
-
The final check at patients bedside is the last opportunity to detect an
identification error & prevent a potentially incompatible transfusion,
which may be fatal.
Instructions for transfusion –
Component
W.B / PRBC
Start transfusion
Within 30 min of
removing from refigerator
Complete transfusion
unless otherwise ordered,
transfusion should be completed
within 2 hours maximum 4 hours
Platelets
FFP
Immediately
As soon as possible
Within 20 min
Within 20 min
after thawing.
Disposable equipment for blood administration –
Transfusion should be given with a sterile, pyrogen free & disposable transfusion set
with filter. ( pore size = 170 – 260 microns )
Warming of blood –
There is no evidence that warming the blood is beneficial to the patient when the infusion
is slow. At infusion rates greater than 100 ml/min, cold blood may be the contributing factor in
cardiac arrest. Howeve,r keeping the patient warm is probably more important than warming the
infused blood.
Warmed blood is commonly required in –
1. Large volume rapid infusions
a) Adults – greater than 50 ml/kg/hr
b) Children – greater than 15 ml/kg/hr
2. Exchange transfusion in infants
3. Patients with clinically significant cold agglutinins
Blood should only be warmed in the blood warmer.
Blood should never be warmed in a bowl of hot water , microwave or radiator ,as this could
lead to haemolysis of RBC’s which could be life threatening. blood should not be warmed above
37 degree centigrade.
RecordsBefore administering the blood components,it is important to write the reason for transfusion in
the patient’s case notes.
If the patient later has a problem that could be related to transfusion ,the records should show
who ordered the blood component & why. This information is useful for conducting an audit of
transfusion practice.
The records you make in the patients case notes is the best protection if there is any medico legal
challenge later on.
Pharmaceuticals & blood –
Do not add any medicines or any infusion solutions other than normal saline to any blood
component..
Red cells should NOT be administered with I.V. solution containing Calcium,dextrose or
ringer’s solution.
Medication should never be added to blood or its components.
no use a separate IV line if an intravenous fluid has to be given at the same time as blood
components.
Medications that can be admisinstered “IV PUSH ” may be administered by stopping the
transfusion ,clearing the line at medication injection site with 5 – 10 ml of normal saline
,administering the medication , reflushing the line with normal saline & restarting the
transfusion. This manoeuvre should not result in the transfusion of red cells exceeding 4 hours.
Monitoring of patient –
Before commencing the transfusion it is essential to encourage the patient to notify a nurse or
doctor immediately if he /she becomes aware of any reactions such as shivering, flushing, pain or
shortness of breath or begins to feel anxious.
Ensure that the patient is in the setting where the patient can be directly observed by the nursing
staff.
For each unit of blood transfused monitor the patient –
a)
b)
c)
d)
e)
f)
Before starting the transfusion
As soon as the transfusion is started
15 min after starting the transfusion
Every hour during transfusion
On completion of transfusion
4 hours after completing the transfusion
Severe reactions are mostly present during the first 15 min of transfusion. all the patients &
particularly unconscious patients should be monitored during this period & for first 15 min of
each subsequent unit.
Administer the blood component –
If the patient is febrile, consideration should be given to postponement of blood transfusion,
since the fever may mask the development of a febrile reaction to the blood component
itself.
The need for transfusion must be balanced with the risk of transfusion by the clinician.
Contact the patient’s physician to determine if pre-transfusion medications should be
administered.
Verify clinician’s orders for transfusion & any other premedications.
Immediately before transfusion, mix the unit of blood thoroughly by GENTLE INVERSION
(vigorous shaking may damage the red cells)
Record in the patient’s notes – type & volume of each blood component transfused
-
Unique donation number of each transfusion unit
-
Blood group of each transfused unit
-
Time at which the transfusion of each unit commenced &
the time at which it completed.
Signature of the person administering blood.
-
Key points
a. Communication is essential between clinical & blood bank staff
b. Blood bank cannot issue blood without correctly labeled sample & blood
requisition form
c. Blood sample is taken in labeled vials with patients name ,ward ,bed,date &
signature of the person collecting the sample. .
d. For each transfusion ,patient must be monitored by trained member of the staff.
e. If the patient needs further transfusions send new samples for compatibility testing.
f. Same sample should not be used for crossmatching another unit which is to be
transfused later.
g. Although there are over 600 known red blood cell antigens organized in 22 blood
group systems, routine blood typing & crossmatching is usually concerned with
only two systems : the ABO & Rh blood group systems.
h. Send the duly filled transfusion reaction forms to the blood bank in all cases of
transfusion with or without reaction with the doctor’s signature & official seal.
i. Prefer taking blood units one by one
j. Blood once issued will not be taken back by the blood bank.
k. Check the vitals at the tine transfusion is being planned & then ask the attendant to
get the blood from the blood bank so that the practice of returning blood due to
unsettled vitals can be taken care of.
l. Crossmatched & booked blood ,if not needed should be informed to the blood
bank else booking will be automatically cancelled.
m. If two units are booked & only one is taken by the attendant,then the blood
bankshould be informed if they need the second unit or not.
n. If a particular unit is available in the sharda blood bank & still brought from
outside,then it should not be crossmatched here.
o. The time at which the blood is issued from the blood bank will be noted here.
p. The time at which blood is received in the concerned ward/deptt should be noted.
q. The time at which the transfusion is started & the time which it ends should be
recorded & noted in patient”s case sheet.
Transfusion reaction –
i)
ii)
iii)
iv)
v)
vi)
If the patient appears to be experiencing an adverse reaction, stop the transfusion &
seek urgent medical assistance.
Note the time of the reaction..
Do not discard the blood bag & the infusion set. RETURN IT TO THE BLOOD
BANK for investigations.
Record the clinical details & the treatment in the patient’s case sheet.
Properly labeled post transfusion blood sample from the vein of opposite side should
be taken in plain & EDTA vials.Blood sample for investigation should always be
taken from the vein of the opposite hand if there is an I/V drip in one arm.
Properly labeled sample of the first voided urine following the reaction.
REFERENCES –
1.
2.
3.
4.
5.
6.
7.
American association of blood banks – transfusion practices
AABB Technical manual
Transfusion procedures approved by Michigan hospitals,USA
Australian & New Zealand society of blood transfusion
California blood bank society
Pathwest
Medscape reference.