Download Transfusion of blood products: a prompt for patient discussion

Transfusion of blood products: a
prompt for patient discussion
Before completing the blue documentation in the ‘Information given for transfusion’ section of the Blood Product
Request form, the following suggested outline should be used to inform our patients about transfusions of blood and
blood products.
Explain:
Reason for, or likelihood of, the need for transfusion.
Nature of the proposed or potential transfusion therapy and what is involved.
Benefits expected.
Risks including common and rare.
Alternatives including the risk of doing nothing.
Ask:
Is there anything else the patient would like to know?
Is there anything the patient does not understand?
Provide:
Written information. Peter Mac’s ‘Blood transfusions’ and ‘Platelet transfusions’ patient information
brochures are available in English on the Peter Mac intranet via iPolicy and in hard copy from
Peter Mac’s Blood Bank.
Department of Health Blood Matters consumer information is available in many languages and can be
downloaded at www.mytransfusion.com.au/node/resources-0
Use a National Accreditation Authority for Translators and Interpreters (NAATI) accredited for nonEnglish speaking patients.
Refer to iPolicy 8.1.1.17 Requesting an Interpreter
Peter MacCallum Cancer Centre - Created by Transfusion Nurse Consultant, September 2013.
Risk category
Specific risk
Frequency
Human error
Incorrect labelling of pre-transfusion blood sample or
incorrect patient identification at any time during transfusion process
1 – 5% of all transfusions
Incorrect blood component transfused
1:10000 due to phlebotomy, laboratory, or bedside
errors
WBIT (Wrong blood in tube)
1:2000
Inappropriate or unnecessary transfusion
1:50000 due to an erroneous decision, or incorrect
information used, to make the decision to transfuse.
Handling and storage errors
1:20000
Acute haemolysis. ABO incompatibility
1: 40,000 ABO/Rh incompatible; 1: 76,000 acute;
< 1:1 million fatal. Usual cause is human error.
Delayed haemolysis non-ABO haemolytic reaction
1:2,500 – 11,000
Febrile non haemolytic transfusion reaction
1% of all transfusions most frequently in patients
previously alloimmunised by transfusion.
Alloimmunisation
Common, due to exposure to foreign HLA, red cell
and other antigens. Often does not cause clinical
consequences but may be severe.
Allergic
Up to 1 – 3% of plasma-containing components; Mild
reactions common, severe reactions are uncommon.
Anaphylaxis
Variable: reports ranging from 1:20,000 – 50,000.
Transfusions.
Transfusion related acute lung injury (TRALI)
Under-reported, probably up to 1:5,000 to 10,000.
Transfusion associated graft-v-host disease (TA-GVHD)
Rare, but USUALLY FATAL.
Immunological
All cellular products are irradiated at Peter Mac to
prevent this.
Physical
metabolic
Post-Transfusion Purpura (PTP)
Rare.
Hyperkalemia, Citrate toxicity, Hypothermia
Rare, except in rapid, large volume transfusions.
Transfusion associated circulatory overload
Up to 1%.
Iron overload
Proportional to cumlative exposure to red cells;
> 20 red cell units
Risk category
Agent and testing standard
Window period
(days)
Estimate of residual risk ‘per unit’
Infectious
HIV, Human Immunodeficiency Virus
(antibody + NAT)
5.9
< 1 in a million
HCV, Hepatitis C Virus (antibody + NAT)
2.6
< 1 in a million
HBV, Hepatitis B Virus (HBsAg + NAT)
15.1
Approximately 1 in468,000
HTLV I & 2, Human T-Cell Lymphotropic Virus
(antibody)
51
< 1 in a million
Malaria (antibody)
7-14
< 1 in a million
Variant Creutzfeldt-Jakob Disease (vCJD)
No testing
Possible. To date no cases in Australia.
Cytomegalovirus (CMV)
Risk especially if immunosuppressed CMV
negative recipients.
Recommendation on back of on BPRF &
MR/16AA.
Syphilis (antibody)
Rare. ↑ incidence of syphilis notifications.
Parasites
Extremely rare.
Bacterial contamination
Variable
1 : 75,000 platelets; 1 in 500,000 red cells
The Blood Service performs bacterial
screening on all platelet products.
Peter MacCallum Cancer Centre - Created by Transfusion Nurse Consultant, September 2013.
No cases of transfusion-transmitted HCV reported in Australia since 1991, none for HTLV since testing commenced
in 1993, none for HIV since 1998 and 2 possible cases of HBV in the 2005-2010 period.
The risk estimates for HIV, HCV and HBV are based on Blood Service data from 1 January 2011 to
31 December 2011. The HTLV estimates are based on data from 1 January 2010 to 31 December 2012.
http://www.transfusion.com.au/adverse_events/risks/estimates
How do these residual risk estimates compare to the risks associated with everyday living? When
considering the significance of specific risks, it is often useful to compare them to the risks associated with
everyday living.
The risks of transfusion transmitted infection with virus is very small compared to risks of everyday living — the
chance of being killed in a road accident is about 1 in 10,000 (see Calman Chart) per year which is considered a
‘low’ risk. Comparatively, all the viral risk estimates are well below this level, being considered as either ‘minimal’
(HBV) or ‘negligible’ (HIV and HCV).
The Calman chart for explaining risk (UK risk per 1 year)
Classification
Risk range
Example
Negligible
Minimal
Very low
Low
Moderate
<1,000,000
1:100,000–1:1,000,000
1:10,000–1:100,000
1:1,000–1:10,000
1:100–1:1,000
High
>1:100
Death from a lightning strike
Death from a train accident
Death from an accident at work
Death from a road accident
Death from smoking 10 cigarettes
per day
Transmission of chickenpox to
susceptible household contacts
Source: Calman K. Cancer: science and society and the communication of risk. BMJ 1996; 313:801.
What is informed consent? Informed consent is consent obtained as a result of a process where the patient is
provided with information, advice and warnings about the treatment, risks, benefits and alternatives. The process
involves a two way conversation with the patient that takes into consideration patient language and cognitive ability,
giving them the opportunity to ask questions and make statements about what is important to them. Provision of
written material is also recommended to supplement verbal information.
What if my patient is not capable to consent? If a patient is not capable of consenting to his/her own treatment,
consent should be obtained from the ‘person responsible’ (as defined in the Guardianship & Administration Act
1986), unless it is emergency medical treatment within the meaning of that Act.
What if my patient refuses a transfusion? Patients have the right to refuse a transfusion of blood and/or blood
products. A competent patient may, at any time, refuse a transfusion or withdraw previously given consent to
transfusion. In all cases of refusal of a transfusion of all or certain blood products:
• A ‘Refusal of treatment’ certificate must be completed; this is available by
hyperlink in iPolicy 9.1.5 Right to refuse treatment. On this certificate a table has been
included to assist you and the patient detail specifically which blood products have been refused AND which are
still deemed acceptable.
– The certificate once completed and scanned is able to be viewed via the Advance Care tab on Verdi.
• The ‘Documentation of information given for transfusion’ section on the
Blood Product Request form must be completed by the MO by writing ‘Refusal of all or certain
blood products’. The MO must be sign and date this form and send to Blood Bank where the transfusion
refusal date will be entered in the patient’s pathology transfusion profile on Verdi.
• Refer to iPolicy 11.1.1.32 Blood sparing optimisation strategies. This guideline
outlines the management of
patients who refuse blood products:
– prior to elective surgery
– who have clinically significant or life-threatening bleeding
– have severe anaemia
– any other situations for the consideration of blood conservation techniques.
Peter MacCallum Cancer Centre - Created by Transfusion Nurse Consultant, September 2013.
Jehovah Witness patients
Most Jehovah Witness patients carry a ‘Medical directive’ which clearly states their view on the non-administration
of blood and blood products. Acceptance of blood products is generally a matter of personal discretion and religious
conscience. Each patient must be treated on an individual basis; all options should be discussed, with the
acceptability determined for each product.
How long is consent for transfusion valid at Peter Mac?
Non-surgical patients: All patients receiving a blood product should be consented prior to the transfusion episode.
Patients undergoing regular/frequent transfusions must be consented to receive all or certain blood products at
the commencement of their treatment or as their condition evolves and the indication for transfusion changes. This
consent will remain valid for the duration of their treatment unless there is a significant change in the indication or risk
profile of transfusion.
Surgical patients: Patients who are receiving a transfusion associated with surgery must be consented to receive all
or certain blood products prior to this episode of transfusion. Consent to transfusion during surgery is included in
the ‘Theatre Booking and Consent Form MR/60-1G’. This consent is valid for the immediate post-operative period
until recovery is complete.
Emergency transfusions: Will be administered and consent sought at the earliest opportunity.
How can I establish if my patient has previously consented to transfusion? The date consent was obtained
is entered into the patient’s Verdi ‘Pathology transfusion profile’.
Consent for surgical patients can be viewed under the Verdi ‘Scanned docs consent-treatment’ tab.
Peter MacCallum Cancer Centre - Created by Transfusion Nurse Consultant, September 2013.