Download Blood Transfusion Policy

Blood Transfusion Policy
Approved by:
Clinical Governance
Committee
On:
November 2007
Review Date:
November 2009
Directorate responsible
for Review
Nursing and Quality
Policy Number:
NP001
Signature:
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
.....................................................
Anna Barrett
1 of 49
Director of Nursing &Page
Quality
Blood Transfusion Policy
Policy for the Prescribing, Collection, Storage and
Administration of Blood and Blood Components for Adult
Patients in Community Hospitals
Written by:
Name
Name
Tracy McDowall
Senior Nurse Community Hospitals
Karen Connor
Lead Practitioner Intermediate Care
CONTENTS
Section
Title
Page
Contents
3
1.
Introduction
5
2.
Purpose
5
3.
Statutory Requirements
5
4.
Accountability and Responsibility
• Medical Staff
• Nursing Staff
• Integrated Team Managers (Matron) – Hospitals
6
5.
Prescribing Blood / Blood Components
8
6.
Requirement for Taking Blood Transfusion Samples
• Identification of the patient
• Labelling of blood samples
9
7.
Procedure for the Receiving Transferred Blood from UHL NHS Trust to a
Community Hospital
11
Collection of Blood Components from Blood Refrigerators
12
8.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 2 of 49
9.
Administration of Blood or Blood Components
14
10.
Monitoring of Patients During Transfusion
17
11.
Management and Investigation of Transfusion Reactions
11.1 Haemolytic transfusion reaction
11.2 Immediate haemolytic reaction
11.3 Delayed Haemolysis
11.4 Febrile non-haemolytic transfusion reactions
11.5 Allergic reactions
11.6 Anaphylaxis
11.7 Septic shock
11.8 Transfusion related acute lunge injury
11.9 Fluid overload
11.10 Late complications
17
18
18
19
19
20
20
20
21
21
21
12.
23
13.
Routine Disposal of Used Blood Packs and Blood Giving Sets
Procedure for the Inter-Hospital Transfer of Patients Whilst Receiving
Blood Components
14.
Emergency Use of O Negative Blood and Group Specific Blood
24
15.
Use of Coagulation Factor Concentrates for the Reversal of
Anticoagulation Over-dosage
25
16.
Transfusion of Albumin Solutions and IV Immunoglobulin Preparations
25
17.
Vicarious Liability
25
References / Bibliography
25
Appendix 1
Blood Component Prescription and Administration Chart
28
Appendix 2
Management of Transfusion Reaction Flow Chart
29
Appendix 3
UHL Guidelines on Red Cell Transfusions
30
Appendix 4
The UHL Guidelines for the use of Platelet Transfusions
36
Appendix 5
Audit Tool
• Blood Transfusion
• Blood Fridges
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
23
41
45
Page 3 of 49
1.
INTRODUCTION
It is well recognised that most errors in blood transfusion practices are operational
rather than technical. Thus, errors in obtaining and labelling blood samples,
requesting, storage, collection and administration of blood or blood components can
lead to significant risks to patients. Many ‘wrong blood’ episodes involve multiple
errors at various stages of blood transfusion process. It is believed that such errors
can be prevented if appropriate steps are taken to ensure that transfusion practices
are performed to high standards of safety and effectiveness.
The procedures set out in this document, which must be considered in its entirety,
constitute the Leicestershire County and Rutland Primary Care Trust policy for
transfusion of blood and blood components. These have been based and are in line
with UHL NHS Trust Policy (2007)
The contents of this policy are broadly based on the national guidelines, ‘The
administration of blood and blood components and the management of transfused
patients’ published in 2004. The guidelines reflect current professional opinion and
have been produced by the British Committee for Standards in Haematology, in
collaboration with the Royal College of Nursing and the Royal College of Surgeons of
England.
It is the responsibility of the PCT to provide a representative on the Blood Transfusion
Committee who will monitor compliance with the Blood Transfusion Policy for the PCT
2.
3.
PURPOSE
2.1
The purpose of the policy is to detail best practice and to reduce the
potential risk of transfusion errors and to assist identified practitioners
with all aspects related to blood and blood product transfusion.
2.2
This policy aims to provide a safe procedure from the transportation,
and collection to the administration of blood components to patients. It
covers UHL guidelines for red cell, plasma and platelet transfusions.
STATUTORY REQUIREMENTS
3.1
Two EU Directives - 2002/98/EC and 2004/33/EC have been
transposed into UK criminal law through the Blood Safety and Quality
Regulations 2005 (Statutory Instrument 2005/50 and Statutory
Instrument 2005/1098). These regulations set standards for quality and
safety for the collection, testing, processing, storage and distribution of
human blood and blood components.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 4 of 49
3.2
This policy has been updated following publication of the above legal
documents and current guidelines.
It is, therefore, essential that all health care professionals and other staff
responsible for, or involved in, any stage of the handling and
administration of blood or blood components, are able to:
A)
B)
4.
Identify and understand their role in the safe handling and
administration of blood.
Complete that role safely.
3.3
The fate of all blood products must be traceable from donor to recipient.
3.4
Data needed for full traceability from donor to recipient and recipient to
donor shall be kept for at least 30 years ( EU2002/98 Feb 2003). This
requires patient medical records to be kept for a minimum of 30
years.
3.5
It should be noted that the risk of transmitting viruses with the
transfusion cannot be entirely excluded
3.6
Consent should always be obtained from patients prior to a transfusion
following the PCT’s Consent to Examination and Treatment Policy.
Where a patient refuses a blood transfusion, either on the grounds of
religious belief or other, the G.P / Consultant should seek advice from
the Blood Transfusion service.
ACCOUNTABILITY AND RESPONSIBILITY
4.1
All staff involved in the transfusion process should be familiar with the
PCT’s policy and associated policies, as well as with their own
professional responsibilities
4.1.1 Medical Staff
4.1.1.1
Medical staff are accountable for the appropriate use of
blood and alternatives to transfusion
4.1.1.2
All staff prescribing blood transfusions are
accountable for ensuring that:
• The patient understands the need for a blood
product transfusion and, where blood is
prescribed is issued with a supporting
information leaflet
• The component, quantity, duration of
transfusion and any special instructions are
clearly prescribed
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 5 of 49
•
•
•
The blood request form is correctly
completed with the patients details
The decision to transfuse and the clinical
outcome is clearly documented in the
patients medical notes
They are aware of how to investigate and
manage blood product transfusions
4.1.2 Qualified Nursing Staff
4.1.2.1
Qualified Nurses are accountable in following the
PCT’s policy, NMC Guidelines and associated policies
4.1.2.2
That they are up to date in the following mandatory
training:
• Blood Transfusion
• Anaphylaxis
• Basic Life Support
• Infection Control
• Their annual I.V administration and Blood
Transfusion competency is up to date
4.1.3. Integrated Team Managers / Matron (Hospitals)
4.2
4.1.2.1
Integrated Team Managers / Matron are responsible
for ensuring that staff receive mandatory training on
Blood Transfusion
4.1.2.2
For ensuring that essential equipment is in place and in
good working order i.e.: Blood fridge, Transit Boxes etc
4.1.2.3
In ensuring an annual audit of blood transfusion
practice and competency is carried out
All staff authorised and trained to undertake venepuncture are
accountable for:
• Correctly identifying the patient verbally
• Using the correct blood request form for Group and Save
• That the patients details on the wrist band (hospital only)
correctly match those on the blood request form. Wristbands
should be checked using the patients NHS number
• Take the correct blood samples using correct bottles
• This accountability is applicable whether using the Leicestershire
sample tubes or different tubes used by other provide
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 6 of 49
5.
PRESCRIBING BLOOD OR BLOOD COMPONENTS
Prescribing blood and blood components is the sole responsibility of medical
staff and no other members of staff are authorised to prescribe blood.
5.1
Medical staff are responsible for:
5.1.1
Prescribing blood component on Blood Component Prescription
Chart (Appendix 1), specifying:
•
•
•
•
•
•
The type of blood component required.
Volume or quantity to be transfused.
Rate or duration of infusion.
Special requirements such as gamma irradiated, CMVseronegative, HLA matched etc. These specifications
must always be clearly stated both on the crossmatch
request form and the blood prescription chart.
Any medication required before or during transfusion.
If a patient’s clinical condition requires more frequent
observations during transfusion than are routinely
indicated on the prescription chart.
The Blood component Prescription Chart should be
photocopied onto pink paper for ease of identification
5.1.2
Explaining risks and benefits of proposed transfusion therapy to
patients and obtaining their informed consent (details must be
recorded in patient notes). Patients should be offered
information leaflets on blood transfusion at the time of
proposing this treatment.
(A supply of leaflets can be obtained by contacting the
http://www.blood.co.uk/hospitals/library/pi/index.htm)
5.1.3
The investigation and management of adverse transfusion
reactions and reporting any severe adverse event to the blood
transfusion laboratory.
5.1.4
Authorising the blood component request form (“cross-match”
form), which must contain the following information:
• Patient’s Surname.
• Patient’s Forenames (initials not sufficient).
• Patient’s Date of birth (age not sufficient).
• Patient’s NHS number or Hospital number.
• Patient’s Gender.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 7 of 49
•
•
•
•
•
•
•
•
•
•
5.15
Red cells will normally be reserved for the patient for only 48hrs
after the date requested unless special arrangements have been
made with the laboratory.
5.16
Blood transfusions should only be administered between 08.30
and 17.30 hours, to maintain patient safety
5.16
If patients are receiving long-term transfusion therapy for the
same indication, the indication and explanation offered to
patients need not be documented for each transfusion episode,
but these must be fully documented for the initial episode.
•
•
6.
Patient’s Location.
G.P in charge of the patient.
Time and date of request.
Time and date the blood component is required.
Relevant clinical details and precise indication for
transfusion (unqualified terms such as anaemia or ↓Hb
are not acceptable).
When requesting red cells, the pre-transfusion Hb
including the date of test should be given on the
crossmatch form.
The requests for platelets should indicate the patient’s
platelet count and the precise indication.
Name and signature of doctor filling in the request form.
Previous blood group, transfusion history and atypical
antibodies (if known).
Special requirements if any (e.g. gamma irradiated, CMV
antibody negative etc – details of indications for these
requirements are given on the reverse of blood component
(cross-match) request form).
Whether or not transfusion achieved the desired effect (e.g.
clinical improvement, post transfusion Hb etc).
The occurrence and management of any adverse effects.
REQUIREMENTS FOR TAKING BLOOD TRANSFUSION SAMPLES.
6.1
A blood sample for crossmatching may be obtained by the following
members of staff:
ƒ
ƒ
ƒ
Medical staff.
Phlebotomists.
Clinical staff that have been trained for this purpose, for example
nurses, midwives and other health care professionals.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 8 of 49
6.2
Identification of the patient.
6.2.1
All patients must be positively identified. Establish patient’s full
name and date of birth by asking, “what is your full name?” and
“What is your date of birth?” and NOT questions such as “Are
you Mr…….?”.
6.2.2
If the patient is unable to confirm identification details, then two
members of staff as defined under 6.1.1 or 6.1.3, should
confirm identity using patient’s case notes and identification
wristband.
6.2.3
All inpatients must have an identification wristband at the time
of taking “group and save” or “crossmatch” samples. The
national guidelines encourage similar practice in outpatient
settings. The details present on the wrist band should contain
NHS number
6.2.4
In case of patients unable to confirm their identity i.e.: confused,
two qualified trained members of staff (6.1) should check the
unique patient NHS number and or Hospital number on the
patient’s wristband.
6.2.5
Only one patient should be bled at a time to minimise the risk of
error.
6.2.6
6.3
Adults require 1 x 7ml Blood Transfusion sample for group and
save / cross-match.
Labelling of patient’s blood samples.
6.3.1
The person taking the blood samples must label the sample
tubes at the patient’s bedside.
6.3.2
The following minimum patient identification details must be
clearly written on the sample tubes:
• Surname.
• Forenames (not initials).
• Date of birth.
• NHS number.
• Legible signature of the person taking the sample.
• In case the patient is unidentified, a unique identity number,
patient’s gender and approx. age.
6.3.3
Sample tubes must never be pre-labelled.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 9 of 49
6.3.4
Sample details must be handwritten. Do not use addressograph
labels on samples.
6.3.5
The correct time timing of sample collection in relation to
previous transfusion of cellular components (red cells, platelets
and granulocytes) is as follows:
•
•
•
•
•
6.3.6
7.
In the absence of recent pregnancy or transfusion, samples
may be taken up to 6 weeks prior to planned transfusion.
If a transfusion has been given 3-14 days previously, a new
sample must be submitted within 48 hours in advance of the
next transfusion.
If a transfusion has been given 15-28 days previously, new
samples must be submitted within 96 hours (4 days) in
advance of the next transfusion.
If a transfusion has been given more than 28 days
previously, a new sample is required within 7 days in
advance of the next transfusion.
In pregnancy, the sample used for cross-match should be
taken within a maximum of 7 days prior to transfusion.
Samples that are not fully and correctly labelled as specified in
section 6.3.2 will not be processed, and the requesting G.P or
clinical team will be notified accordingly.
PROCEDURE FOR RECEIVING TRANSFERRED BLOOD FROM UHL
NHS TRUST TO A COMMUNITY HOSPITAL
7.1
The receiving community hospital should only accept delivery of blood if
they have access to a identified blood fridge
7.2
The receiving area should document the time of delivery and where
applicable notify the clinical area.
7.3
On arrival the transit box should be checked for integrity, the storage
conditions examined, verify the units, complete the transfer
documentation & send the documentation to blood bank. If there are
concerns over the integrity of the blood products UHL NHS Trust Blood
Bank should be informed and arrangements to return made
7.4
When satisfied with the integrity of blood products, the units should be
transferred to the identified blood fridge.
7.5
Where unexpected problems occur with the blood fridges i.e.:
temperature not maintained, UHL NHS Trust Blood Bank should be
informed and instructions followed
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 10 of 49
7.6
The receiving person must ensure that the transferring units are entered
into stock records, and this also includes products that are not suitable
for transfusion on transfer, or as a result of blood fridge failure.
Information recorded includes:
• Date of blood received
• Time blood received and put into fridge
• Patient Name
• Hospital / NHS Number
• Hospital and Ward
• Bag Serial Numbers
• Expiry date of each unit
• Signature of person placing in fridge
7.7
Blood products should be stored at 4oC to prevent bacterial growth.
7.8
The blood fridges should have a daily check made of the temperature
and this should be recorded for audit purposes.
7.9
Only blood products should be stored within the blood fridge
7.10
Blood must only be stored in a designated blood bank refrigerator and
never in a drug or any other refrigerator.
Platelets must never be stored in any refrigerator and should be (Taken from:
Appendix 13 UHL Blood Transfusion Policy 2007)
8.
COLLECTION OF BLOOD COMPONENTS FROM BLOOD BANK
REFRIGERATORS.
8.1
The staff responsible for the administration of blood component must
ensure that a suitable intravenous access, patient’s consent and pretransfusion observations have been secured and recorded prior to
collection of blood and that the blood components have been correctly
prescribed.
8.2
The collection must be authorised by a member of staff who is suitably
qualified to administer prescribed blood components, i.e. a doctor,
registered nurse.
8.3
Unqualified members of staff, who has received necessary training for
this purpose, can be authorised to collect blood components.
8.4
The person collecting the blood component from the blood fridge should
take the completed Blood Component Prescription and Administration
chart with them to confirm correct patient details, and if satisfied
complete the blood fridge log book against the section identified ‘blood
component removed from fridge’ with signature and date and time.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 11 of 49
8.5
If there is discrepancy between the supplied details and the label on the
blood or component then advice should be sought from the laboratory
staff.
8.6
The collector must deliver the blood component to requested location
without delay and hand the component to a qualified member of the
nursing staff if applicable. The blood component must not be left on the
ward/theatre without the knowledge of the qualified staff who is
expecting its delivery.
8.7
The qualified member of staff who is responsible for the administration
of blood component must check all patient identification details on the
delivered blood component and the crossmatch report.
8.8
Only one unit of blood should be collected from the blood bank
refrigerator at a time
8.9
Blood or blood component should only be requested immediately prior
to administration and the administration must be commenced as soon
as possible after its arrival on the ward, ideally within 30 minutes.
8.10
Blood may still be administered following a longer period of being left at
room temperature, providing transfusion of that unit can be completed
within 4 hours of removal from the blood bank fridge.
8.11
For adult patients under normal circumstances a unit of red cells can be
safely given over a period of 2 to 3 hours.
8.12
If significant delays occur the Blood Transfusion Laboratory must be
informed, and arrangements made for returning the component to the
Blood Transfusion Laboratory. The time of return must be documented.
The fate of all blood products must be traceable from donor to recipient. This is a
legal requirement. Therefore any unused products must be returned to the Blood
Bank. All wastages must be reported to the laboratory to complete audit trail.
NB: Partial transfusions however small should be recorded as transfused and be
documented accordingly.
9.
ADMINISTRATION OF BLOOD OR BLOOD COMPONENTS
9.1
The following members of staff are authorised to administer the
prescribed blood or blood components only if they possess evidence of
annual blood transfusion training:
• Doctor.
• Registered Nurse.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 12 of 49
9.2
Immediately before setting up the transfusion, two qualified members of
staff (see 9.1) must take the following to the patient
ƒ The unit of blood component to be transfused.
ƒ The cross-match report.
ƒ The Blood Component Prescription and Administration Chart
ƒ Patient’s case notes.
ƒ The appropriate blood component giving set.
ƒ UHL Audit Card (orange)
9.3
Student nurses, OPD and ODP professionals should only act as a 3rd
checker
9.4
The patients consent should be obtained in line with the PCT Consent
Policy prior to the transfusion being set up and clearly documented in
their nursing documentation
9.5
The patient must be positively identified by asking his/her Surname, first
name and date of birth, whenever possible.
9.6
Ensure that the first name, the surname and their date of birth are the
same as on the patient’s wristband is verbally clarified.
IMPORTANT:
9.7
It is essential that any patient having a blood transfusion has an
identification wristband, or equivalent e.g. photo ID card with
unique patient identifiers
Make absolutely sure that (i) Surname, (ii) Forenames, (iii) Date of birth
and (iv) Unique patient identification number (e.g. NHS and / or hospital
number) is checked and found to be identical with:
•
•
•
•
•
The patient’s identification wristband or equivalent (see above).
The cross-match report.
The compatibility label attached to the blood pack.
Patient’s case notes.
The Blood Component Prescription and Administration chart.
9.8
If the blood group of red cells units and the blood group of the
patient are not identical, DO NOT START TRANSFUSION AND
IMMEDIATELY CONTACT BLOOD TRANSFUSION LABORATORY
FOR ADVICE.
9.9
Occasionally the blood groups of platelets may not be identical to the
patient’s blood group. This will be stated on the crossmatch report.
Units may be issued by the blood bank with the following stickers where
products with alternative blood group are issued. If in doubt contact the
Blood Transfusion Laboratory.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 13 of 49
Blood group of component does
not match patient. However
It is safe to transfuse
9.10
The compatibility label on the blood pack must also be checked and
found identical with the crossmatch report for the following details:
•
•
•
•
The blood- pack number.
The component type.
Expiry date.
Any special requirement such as gamma irradiation, CMVnegative. Such special requirements should also be checked on
the blood prescription chart.
9.11
After ALL patient checks have been satisfied, BOTH qualified staff
members must sign the crossmatch report, against the blood unit being
given. In the event of any discrepancy, transfusion must not proceed
and further advice obtained from the Blood Transfusion Laboratory.
9.12
It is absolutely essential that each of the two members of staff carrying
out the patient checks is vigilant and one does not rely upon the other to
be rigorous.
9.13
The person attaching the unit of blood component to the patient must
also sign the Blood Component Prescription and Administration chart
and enter the start time and date.
9.14
Baseline observations will need to be recorded prior to the collection of
blood. (Refer to section 10.0).
9.15
Check the Blood Component Prescription and Administration chart to
ascertain the prescribed blood component and its infusion time, whether
any pre-medication or diuretic need to be given, or if there are any
special requirements, such as CMV seronegative or irradiation.
9.16
The flow rate must be adjusted according to the prescription. The flow
rate should be set using a drip rate formula
9.17
The same patient check procedure is required for each subsequent unit
of blood. The crossmatch report accompanies the first unit only, and
during the transfusion it must be secured in case notes or the patient’s
observations folder at the end of the bed, together with the Blood
Components Prescription and Administration chart.
9.18
After completion of the transfusion procedure, the Blood Component
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 14 of 49
Prescription and Administration chart, the cross-match report and any
additional observation chart used for monitoring transfusion, must be
filed in patient’s case notes as a permanent record.
9.19
At the completion of each bag of blood administered the orange
UHL audit card should be completed and returned to Blood Bank at
the Leicester Royal Infirmary. This should be completed even if the
transfusion was not complete and / or blood was wasted
9.20 The blood giving set must be changed after two units of the same
blood/blood component or after 8 hours or if the filter is found to be
blocked, whichever occurs first. Blood / blood components must not be
transfused in the same blood giving set following the infusion of other
intravenous fluids.
9.21 Electronic infusion pumps are not recommended for transfusion of
blood as they may damage blood cells.
9.22 Always wear gloves and aprons when handling blood components.
IMPORTANT:
Blood can only be warmed using appropriate blood warming
equipment with built in thermostat and an audible alarm. Blood
MUST never be exposed to temperatures of over 40ºC as this
can cause severe transfusion reactions. Check with the blood
transfusion laboratory, if in any doubt.
Blood must never be warmed on radiators, in hot water,
microwaves or other heating equipment not specifically
designed for this purpose. Failure to comply with this
requirement is likely to result in severe red cell haemolysis with
potentially lethal consequences.
9.23
10.
General Instructions:
•
Drugs must not be added to blood under any circumstances.
•
Blood component packs should be inspected prior to transfusion,
for any leaks at the ports and seams and for the presence of
clots and must not be used if any such defect is noticed.
•
The transfusion of a unit of red cells should be completed within
a 4 hours period.
MONITORING OF PATIENTS DURING TRANSFUSION
10.1
The health care professionals responsible for the care and monitoring of
transfused patients are defined above under section 9.1.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 15 of 49
11.
10.2
Baseline vital signs i.e. PULSE, BLOOD PRESSURE, RESPIRATION
AND TEMPERATURE must be checked just before the collection/
setting up the transfusion, and again 15 minutes and 60 minutes after
the start of EACH PACK of blood or blood component (This information
must be completed using the Blood Component Prescription and
Administration chart).
10.3
The patients observations should be recorded hourly until the
completion of the blood transfusion unit, and also on completion.
Observations taken should be recorded on the Early Warning Score
Chart.
10.4
The observations in 10.2 above are the minimum. More frequent
observations may be necessary should the patient become unwell, or in
other clinical situations e.g. unconscious or heavily sedated patients and
patients with heart failure.
10.5
Most serious transfusion reactions tend to occur within the first 15
minutes of starting a new blood or blood component pack and the
patient must therefore receive very close visual observation during this
time.
MANAGEMENT AND INVESTIGATION OF TRANSFUSION REACTIONS
A reaction to the transfusion of blood products may be mild or severe and life
threatening e.g. a haemolytic reaction due to ABO incompatibility, sepsis
because of bacterially contaminated blood products. Adequate management
depends on the likely nature of a transfusion reaction. It will be frequently
necessary to seek specialist advice from senior haematology medical staff.
All reactions, errors and near misses MUST be reported to the blood
transfusion department and their advice and recommendations followed
Suspected Serious Hazards of Transfusion (SHOT) should be reported
following the PCT’s policy on the reporting of untoward incidences where
patients have required transfer to secondary care as a result of their
transfusion
11.1
Haemolytic transfusion reaction
“Haemolytic transfusion reaction is one in which signs of increased red
cell destruction are produced as a result of transfusion.”
A distinction is made between an immediate reaction and one in which
destruction begins only after there has been an immune response
provoked by the transfusion.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 16 of 49
11.2
Immediate haemolytic reaction
“This may be caused by the transfusion of incompatible red cells,
bacterially contaminated or thermally damaged blood.”
Incompatible red cells react with the patient's own anti-A or anti-B,
activating complement, causing intravascular haemolysis and
disseminated intravascular coagulation (DIC). Transfusion of ABO
incompatible blood almost always arises from errors in labeling the
sample or from inadequate pre transfusion bedside checks. If a unit is
mistakenly transfused to a patient other than the one from whom the
sample was received the chances of ABO incompatibility are about 1 in
3. The reaction is usually most severe when group A red cells are given
to a group O patient. In a conscious patient only a few mls, may be
needed to cause a severe reaction within minutes of commencing
transfusion. In an unconscious patient some of the symptoms will not
be evident.
11.2.1 Clinical features:
• Fever, chills or rigor.
• Tachycardia.
• Hypotension and circulatory collapse.
• Severe pain at drip site.
• Pain in back or chest.
• Dyspnoea.
• Haemoglobinaemia.
• Acute oliguria, renal failure and collapse.
• Disseminated intravascular coagulation (DIC).
11.2.2 Management
• Stop the transfusion without delay.
• Dial 999
• Resuscitate the patient.
• Return all blood packs and the drip set to the Blood
Transfusion Laboratory.
11 .3 Delayed haemolysis
The titre of an antibody in a recipient's plasma may be too low to be
detected in the pre-transfusion tests. However, if incompatible red cells
are transfused a secondary response may be provoked. A few days
after transfusion there is a rapid increase in antibody with consequent
destruction of transfused red cells.
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Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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11.3.1 Clinical features:
• Fever (not always present).
• Fall in haemoglobin level.
• Jaundice (often not before day 5 post-transfusion and
can be as late as day 10).
• Haemoglobinuria (a mean of 8 days post-transfusion).
11.3.2 Management
• Take samples for:
o FBC.
o LFT.
o Direct Antiglobulin Test (Coombs test).
o Antibody screening.
•
11.4
Inform Blood Transfusion Laboratory staff and discuss
with senior haematology medical staff.
Febrile non-haemolytic transfusion reactions (FNHTR)
Mild febrile reactions are often caused by cytokines in blood
components or patient antibodies to donor leucocyte antigens. These
often occur towards the end of the transfusion and there are no clinical
signs other than a rise in temperature and non-specific accompaniments
of any pyrexia. NHFTRs are now seen relatively less frequently
because of universal leucodepletion of blood components.
NHFTRs are unpleasant but not life threatening. Paracetamol is often
all that is required.
However, it is important to remember that a mild febrile reaction may be
the early stages of an acute haemolytic transfusion reaction caused by
incompatible or bacterially contaminated blood. If a patient becomes
unwell or hypotensive, transfusion must not be restarted and blood
transfusion laboratory must be informed who will arrange the return of
the blood component pack and additional blood samples from patient for
necessary serological and microbiological investigations.
11.5
Allergic reactions
Caused by antibodies in the patient to infused plasma proteins or
infusion of allergens, which react, with patient’s IgE antibodies. More
likely to occur with platelets and plasma than red cell concentrates.
11.5.1 Clinical features (within minutes of the transfusion):
• Urticaria.
• Itching.
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Nursing and Quality Directorate
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Symptoms usually subside if the transfusion is slowed and antihistamine
(e.g. chlorpheniramine 10mg i.v.) is given by slow injection.
Hydrocortisone 100mg i.v. may also be used.
11.6
Anaphylaxis
This is a very rare but life-threatening complication. The onset is rapid
and often dramatic. Immediate action is required. In some cases this is
associated with antibodies against IgA in patients who have severe IgA
deficiency. Antibodies to other plasma proteins may be implicated in
other cases.
11.6.1 Management
• Discontinue transfusion.
• Follow Leicestershire County and Rutland PCT
Anaphylaxis Policy
• Dial 999
• Inform the Blood Transfusion Laboratory.
• Under no circumstances should transfusion be restarted.
• Return all blood packs and the drip set to the Blood
Transfusion Laboratory.
11.6.2 Future transfusions
•
11.7
Washed cellular blood components or selected blood
components from IgA deficient donors may be needed
for future transfusion.
Septic shock
Although this complication is extremely rare with a reported incidence of
two cases per million blood components transfused, the mortality
remains very high. This is caused by bacterial contamination of red
cells or platelets.
11.7.1 Clinical features:
• Usually acute with rapid onset.
• Pyrexia.
• Hypotension.
• Tachycardia.
• Collapse.
11.7.2 Management includes
• Dial 999
• Discontinuation of transfusion.
• Return all blood packs and the drip set to the Blood
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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•
11.8
Transfusion Laboratory.
Inform the Blood Transfusion Laboratory.
Transfusion related acute lung injury (TRALI)
This rare but life-threatening complication manifests as features of noncardiogenic pulmonary oedema, either during or soon after transfusion.
The cause is usually donor plasma that contains antibodies to the
patient's leucocytes and is a serious condition with a high mortality rate.
11.8.1 Clinical features include:
• Chill.
• Fever.
• Non-productive cough.
• Breathlessness.
• Hypoxia.
• Interstitial shadowing on chest x-ray.
11.8.2 Management is that of acute respiratory distress
syndrome:
• Stop transfusion.
• Immediately seek advice from senior haematology medical
staff and ITU physician.
11.9
Fluid overload
This can occur when correcting chronic anaemia in elderly patients or
those with pre-existing cardiac disease.
11.9.1 Clinical features:
• Dyspnoea.
• Tachycardia.
• Hypotension.
11.9.2 Management:
• Stop the transfusion.
• Give furosemide (frusemide) 40mg i.v. in the first
instance.
• Arrange chest X-ray and ECG.
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Review Date; November 2009
Nursing and Quality Directorate
Page 20 of 49
11.10 Late complications of transfusion
11.10.1 Iron overload
Transfusion dependent patients receiving red cells over a long
period become overloaded with iron. Chelation therapy with
desferrioxamine is used to minimise accumulation of iron.
11.10.2 Graft versus Host disease (GvHD)
This is a rare but often fatal complication of transfusion caused
by T-lymphocytes. Immunodeficient patients e.g. recipients of an
allogeneic bone marrow transplant, foetal intrauterine
transfusions, patients with Hogkin’s disease and patients
undergoing specific chemotherapy such as fludarabine and
cladribine, are at special risk for this disease. It has also
occurred in immunologically normal patients after transfusion of a
first or second degree relative's blood (from shared HLA
haplotypes). It is prevented by gamma irradiation of cellular
blood components given to patients at risk.
11.10.3 Post-transfusion purpura (PTP)
PTP is a rare but potentially life threatening complication of red
cell or platelet transfusion, most often seen in female patients. It
is caused by platelet-specific alloantibodies. Typically 5-9 days
after transfusion the patient develops an extremely low platelet
count with bleeding. Refer to a Consultant Haematologist for
treatment advice. High dose IVIG is the treatment of choice.
Plasma exchange may be required. If platelet transfusion is
absolutely essential, platelets compatible with the patient's
antibody should be used. Likewise any red cell transfusions
should be from donors negative for the implicated platelet
antigen.
11.10.4 Some rare complications of transfusion, such as the
transmission of viral infections may only be recognizable many
days or weeks after the blood products have been given.
Problems of this type should be reported to the blood
transfusion laboratory so that adverse events are effectively
followed up
11.3
In the event of a serious transfusion reaction, the implicated blood
component pack should be sent to the blood transfusion
laboratory, with the giving set still attached to the blood
component pack, and the cannula end of giving set sealed using
an appropriate bung. The blood packs should be double bagged
NP001 – Blood Transfusion Policy
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Review Date; November 2009
Nursing and Quality Directorate
Page 21 of 49
for transporting in a yellow clinical waste bag and clearly identified
with patient identify sticker.
12.
ROUTINE DISPOSAL OF USED BLOOD PACKS AND BLOOD GIVING
SETS
12.1
On completion of uncomplicated transfusion procedure, all used blood
component packs must be placed in a yellow polythene bag used for
disposal of clinical waste and stored in the Sluice area. The bag must
then be sealed, labelled with the patient name, the date of transfusion
and the name of the nurse taking down the blood transfusion. This is to
aid traceability
12.2
These bags must then be retained and kept in a designated area on
each ward/theatre for at least 24 hours. This will make it possible to
investigate any adverse event that may have been attributed to blood
transfusion. After 24 hours, the bags should be disposed of as per the
clinical waste policy.
12.3
The giving sets are disposed of into a sharps bin.
12.4 Partially transfused units that are no longer required must be sealed
using an appropriate bung and discarded as per the clinical waste
policy.
13.
14.
PROCEDURE FOR THE INTER-HOSPITAL TRANSFER OF PATIENTS
WHILST RECEIVING BLOOD COMPONENTS
13.1
If a patient has to be transferred from hospital to another while blood
transfusion is in progress, a registered nurse or midwife, or a member of
medical staff must remain with the patient until transfer is complete.
13.2
The registered nurse responsible for the patient must inform the
technical staff in UHL Blood Transfusion Laboratory giving full details of
the transfer.
13.3
The transferring hospital should ensure that any remaining unused
blood transfusion components are transported in an appropriate transit
box in controlled storage conditions in line with guidance given by UHL
Blood Transfusion Laboratory.
USE OF EMERGENCY O NEGATIVE BLOOD AND GROUP SPECIFIC
BLOOD
14.1
Uncrossmatched, O-Negative blood MUST ONLY be used when there
is life threatening blood loss and the degree of urgency allows no time
to wait for the arrival of group specific or cross-matched blood from the
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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blood transfusion laboratory. This is predominantly for emergency
vehicles and major incidents
14.2
Cross-matched or group specific blood must be used in preference to
O-Negative blood whenever possible.
14.3
Blood transfusion laboratory must be immediately informed of the
degree of urgency and anticipated blood component requirement.
14.4
Patient must immediately be fitted with a wristband with all patient
identity details, or if the patient is unidentified, then the unique identity
number and gender must be used.
14.5
Group specific blood can normally be made available for collection from
the blood transfusion laboratory in 10 minutes of receiving patient’s
blood sample. Crossmatched blood can be made available for
collection in 35-40 minutes of the receipt of samples; unless atypical
antibodies are detected when further laboratory tests will be necessary.
14.6
Units of uncrossmatched, O-Negative blood are available for use in
extreme emergency, and available in the following community blood
bank refrigerator:
14.6.1 Loughborough General Hospital
• Blood bank refrigerator in Pathology (2 units).
15.
14.7
The blood transfusion laboratory must be immediately notified if O
negative blood is removed from the above blood bank refrigerator to
facilitate prompt replacement of used O-negative units.
14.8
Form supplied with each emergency O negative unit to record details of
patient transfused must be returned promptly to update records. This is
a legal requirement to enable traceability of blood from donor to
recipient.
USE OF COAGULATION FACTOR CONCENTRATES FOR THE REVERSAL
OF ANTICOAGULANT OVERDOSAGE
15.1
Patients diagnosed with haemophilia should be treated in secondary
care
15.2
Reversal of Warfarin and/ or in life threatening haemorrhage should be
treated in secondary care
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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16.
TRANSFUSION OF ALBUMIN SOLUTIONS AND IV IMMUNOGLOBULIN
PREPARATIONS
16.1
17.
This is not a routine practice for community hospitals.
VICARIOUS LIABILITY
The PCT as an employer will assume vicarious liability for the actions of all
staff, including those on honorary contracts providing that:
•
•
•
•
Staff have undergone all training identified as necessary to perform the
procedure
Staff have been assessed as competent in administering blood
components and have been endorsed by their line manager
That staff have valid professional registration
That staff have followed and adhered to the Blood Transfusion Policy
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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REFERENCES / BIBLIOGRAPHY
This policy has been based on the Blood Transfusion Policy – A Policy for the
prescribing, Storage, Collection and Administration of Blood and Blood
components
(2007) UHLNHS Trust, Leicester
American Association of Blood Banks (1997). Guidelines for blood recovery and reinfuse in surgery and trauma.
Blood Transfusion Services of the United Kingdom. (1996) Handbook of Transfusion
Medicine, 2nd edition (ed. McClelland D. B. L.) HMSO, London.
Blood Transfusion. (1999) Nursing Standards; 14(3): suppl. 1-2.
Bradbury M, Cruickshank J. P. (2000) Blood transfusion: crucial steps in maintaining
safe practice. British Journal of Nursing; 9 (3): 134-138.
British Blood Transfusion Society. http://www.bbts.org.uk
British Committee for Standards in Haematology (BCSH) (1996a) Guidelines for pretransfusion compatibility procedures in blood transfusion laboratories. Transfusion
Medicine, 6, 273-283.
British Committee for Standards in Haematology. http://www.bcshguidelines.org.uk
Department of Health (2002). HSC 2002/009 Better Blood Transfusion 2
European Parliament and the Council of the European Union (2002). Directive
2002/98/EC. HMSO: London.
http://www.fresaniushemocue.com
Linden J. & Kaplan H. (1994) Transfusion errors: causes and effects. Transfusion
Medicine Reviews, 8, 169-183.
Linden J. V, Paul B. & Dressler K. P. (1992) A report of 104 transfusion errors in New
York State. Transfusion, 32, 601-606.
Linden J. V, Wagner K, Voytovich E. & Sheehan J. (2000) Transfusion errors in New
York State: an analysis of 10 years’ experience. Transfusion, 40, 1207-1213.
Marconi M. & Sirchia G. (2000) Increasing transfusion safety by reducing human
error. Current Opinion in Hematology; 7 (6): 382-386.
McClelland D. B. L. & Phillips P. (1994) Errors in blood transfusion in Britain: survey
of hospital haematology departments. British Medical Journal, 308, 1205-1206
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 25 of 49
McClelland, D.B.L (2001). Handbook of Transfusion Medicine (Third Edition). The
Stationery Office: London.
Murphy M. F, Atterbury C. L, Chapman J. F. et al. The administration of blood and
blood components and the management of transfused patients. Guidelines.
Transfusion Medicine, 1999, 9, 227-238.
Serious Hazards of Transfusion (SHOT). http://www.shotuk.org
Serious Hazards of Transfusion, Annual Reports 200-2001, 2001- 2003, 2002-2003,
Serious Hazards of Transfusion Scheme, UK. http://www.shotuk.org
The National Blood Service. http://www.blood.co.uk
The UHL NHS Trust Policy for the Prescribing, Collection, Storage and Administration
of Blood and Blood Components. http://www.uhl-tr.nhs.uk
The Blood Safety and Quality Regulations 2005 No 50 (Statutory Instrument)
Guidelines for compatibility procedures in blood transfusion laboratories. BCSH
Transfusion Medicine, 2004,14,59-73
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
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Appendix 1
BLOOD COMPONENT PRESCRIPTION AND ADMINISTRATION CHART
Patient Addressograph
Note: Some patients will require CMV negative and/or irradiated blood components.
Please see overleaf for clinical indications for these and guidance notes on blood component
Administration and an algorithm for management of transfusion reactions
PLEASE REMEMBER TO OFFER YOU PATIENT A BLOOD TRANSFUSION INFORMATION
LEAFLET
PRE
DATE
BLOOD
COMPONENT
DOSE/
VOLUME
*STATE
IF
CNV
NEG/
IRRADIATED/
HLA
MATCHED
OR
NOT
APPLICABLE
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
RATE OF
INFUSION
OTHER
SPECIFIC
INSTRUCTIONS
E.G.: DIURETIC
REQUIRED
DR.’S
SIG
AND
INITIAL
TIME
DELIVERED
TO WARD
RN
SIG
AND
INITAL
CHECKED BY
SIG
AND
INITIALS
Page 27 of 49
ADMIN
SIG AND
INITIALS
START
TIME
END
TIME
T
E
M
P
P
U
L
S
E
20 MIN
B
/
P
T
E
M
P
P
U
L
S
E
60 MIN
B
/
P
T
E
M
P
Unit
Bar
cod
e
Unit
Bar
cod
e
Unit
Bar
cod
e
Unit
Bar
cod
e
Unit
Bar
cod
e
P
U
L
S
E
B
/
P
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Review Date; November 2009
Nursing and Quality Directorate
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APPENDIX 2 – forms back of Blood Component Prescription Chart
Note: All drug doses given on this
Management of transfusion reaction
algorithm are for adults.
ACTION POINTS
•Stop transfusion
and inform doctor.
• Examine patient
Symptoms/Signs of Acute Transfusion Reaction
Fever, chills, tachycardia, hyper or hypotension, collapse, rigors, flushing,
urticaria, bone, muscle, chest and/or abdominal pain, shortness of breath,
nausea, generally feeling unwell, respiratory distress
Febrile non-haemolytic
transfusion reaction
If temp rises less than 1.5°C, the
observations are stable and the
patient is otherwise well give
Paracetamol, if appropriate.
Restart infusion at slower rate
and take more frequent clinical
observations.
Stop the transfusion and call a doctor
Measure temperature, pulse, BP, respiratory rate, O2 saturation
Check the identity of the recipient, the details on the unit and crossmatch report form
Mild fever
Urticaria
Reaction involves
mild fever or urticarial
rash only?
Mild Allergic reaction
Give Chlorpheniramine 10mg
slowly i.v. (note this is adult dose) and
restart the transfusion
at a slower rate and
observe more frequently
No
• Initiate investigations
ABO Incompatibility
Take down unit and giving set
Return the bag along with the giving set to blood bank
Commence I.V. saline infusion
Monitor urine output/catheterise
Maintain urine output at
> 100 mls/hr Give frusemide if urine output falling
in consultation with renal team
Treat any DIC with appropriate blood components
Inform Hospital Transfusion
Department immediately
and treatment as
appropriate
• Decide if it is safe
to resume transfusion
• Monitor patient
closely
• If in doubt, seek
advice from senior
colleagues, blood
bank / haematologist
Yes
No
Yes
Severe Allergic
reaction?
No
Haemolytic reaction/bacterial infection of unit
Disconnect giving set from canula and return the bag with the giving set
to blood bank with all other used/unused units
Take blood cultures, repeat blood group/crossmatch/FBC, coag screen,
Biochemistry, urinalysis
Monitor urine output
Commence broad spectrum antibiotics if suspected bacterial
infection Commence oxygen and fluid support
Seek Haematological advise
Fluid overload
STOP INFUSION
Give Oxygen and Frusemide40-80 mg i.v. (adult)
Suspected ABO
incompatibility?
Recheck pack and
patient ID
Yes
Other Haemolytic
reaction/bacterial
contamination?
No
Acute
LVF
Acute dyspnoea/
hypotension
Monitor Blood gases perform CXR
measure CVP/Pulmonary capillary
pressure
(H Qureshi/DMarples/tralgoV1/Oct 02 - ref: BCSH)
NP001 – Blood Transfusion Policy
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Nursing and Quality Directorate
Severe Allergic Reaction
Severe Allergic reaction
Bronchospasm, angioedema,
abdominal pain, hypotension
Discontinue transfusion
Return to blood bank the blood pack with attached giving set
along with all other units.
Give Chlorpheneramine 10mg, slow I.V. (adult dose)
Commence oxygen
Give nebulised salbutamol (2.5 to 5mg, adult dose)
If severe reaction, give adrenaline 0.5mg (0.5 mls of 1 in
1000 solution, adult dose) I.M.
Repeat IM dose after 5 minutes if necessary
If severe hypotension, give adrenaline 0.5mg (5 mls of
dilute, 1 in 10,000, adult dose), slow I.V. (1 ml per minute,
stopping when response obtained)
Send 10 mls clotted sample to blood bank
Use saline washed blood components in future
Page 29 of 49
Not
LVF
Transfusion Related Acute Lung Injury
(TRALI)
Dyspnoea, chest x ray,
“whiteout”
Discontinue transfusion
Give 100% Oxygen
Treat as ARDS - Ventilate if
hypoxia indicates
APPENDIX 3
THE UHL GUIDELINES ON RED CELL TRANSFUSIONS
These guidelines are based on national guidelines published by the British
Committee on Standards in Haematology (BCSH 2001) and The Association of
Anaesthetists of Great Britain and Ireland (2001).
The guidelines are intended for adult patients only.
Summary
•
•
•
•
•
•
•
•
•
•
Decision to transfuse should be based on a careful assessment of patient’s
clinical state and haemoglobin.
Blood transfusion must be justified as essential to prevent major morbidity
or mortality.
Alternatives to allogenic red cells should be considered where appropriate.
Document precise indication for transfusion in case notes.
Risks and benefits of transfusion should be explained to patients and their
informed consent obtained. This should be clearly documented in case
notes.
Patients should be offered an information leaflet (the leaflets are available
in all clinical areas and further supplies can be obtained from blood bank).
Preoperative assessment should include diagnosis and treatment of iron
deficiency anaemia with iron supplements.
Hb 10 g/dL or above – normally no red cell transfusion required.
Hb less than 7 g/dL, no further blood loss anticipated – transfuse 2 units of
red cells. Aim to maintain Hb at 8-9 g/dL. In the elderly and in patients with
ischemic heart disease, maintain Hb 9-10 g/dL.
Hb 7-8 g/dL, in a patient who is otherwise stable and no further blood loss
is anticipated, is not normally an indication for transfusion unless the patient
is clearly symptomatic of anaemia.
Background
There is evidence of very significant variation in the use of red cell transfusions
(The Sanguis Study Group, 1994), suggesting that inappropriate use is
widespread.
There are significant concerns about the safety of blood transfusion with
regard to both infectious and non-infectious complications of transfusion, and
the theoretical risk of transmission of variant Creutzfeldt-Jakob disease
(vCJD).
Additional safety requirements are increasing the cost of blood components.
There are serious concerns relating to the sufficiency of blood supply in the
future.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
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General Principles
There is no universal trigger for red cell transfusion. The decision to transfuse
a patient should be based on haemoglobin level and a careful clinical
assessment, indicating that transfusion is necessary to save life or prevent
major morbidity.
Alternatives to allogeneic blood (e.g., peri-operative cell salvage, autologous
predonation etc) should be considered where appropriate.
Patients should be informed of risks / benefits / available options and this
should be documented in case notes. Patient information leaflets are now
available for this purpose and should be offered to patients, wherever possible,
at the time of proposing blood transfusion. (Further supplies can be obtained
from local blood banks).
Reasons for transfusion should be clearly documented in patient notes. A
recent large multidisciplinary audit of transfusion practice within the UHL
showed major deficiencies in this area.
(i):
Acute Blood Loss
It is often difficult to estimate the amount of blood loss in this situation.
Reference to the following table (Basket et al 1990) may be useful for
clinical assessment.
In acute blood loss, crystalloids and/or colloids may be sufficient to
replace up to 20 % blood volume (effects of hypovolaemia vs anaemia).
15% loss (750 ml in adult) – crystalloids only may be sufficient unless
pre-existing anaemia or cardio-respiratory compromise, or further blood
loss anticipated.
15-30% loss (800–1500 mls in an adult) – crystalloids or synthetic
colloids. Need for red cell transfusion unlikely unless pre-existing
anaemia or cardio-respiratory compromise or further blood loss
anticipated.
30-40% loss (1500–2000 mls) – rapid volume replacement with
crystalloids or synthetic colloids – red cell transfusion will probably be
required.
>40% blood loss – refer to protocol for management of massive
haemorrhage. Fresh Frozen Plasma, cryoprecipitate and / or platelets
may be necessary to correct coagulation abnormalities.
NP001 – Blood Transfusion Policy
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Aim to maintain Hb > 9 g/dL. Inform blood bank of the degree of
urgency.
CLASSIFICATION OF HYPOVOLAEMIC SHOCK ACCORDING TO BLOOD LOSS
(BASKETT, 1990).
Class I
Class II
Class III
Class IV
Percentage
<15
15-30
30-40
>40
Volume (ml)
750
800-1500
1500-2000
>2000
Systolic
Unchanged
Normal
Reduced
Very low
Diastolic
Unchanged
Raised
Reduced
Very low
unrecordable
Pulse
(beats/min)
Slight
100-120
120 (Thready)
>120 (Very
thready)
Blood loss
Blood pressure
Tachycardia
Capillary refill
Normal
Slow (>2s)
Slow (>2s)
Undetectable
Respiratory
rate
Normal
Normal
Tachypnoea
(>20/min)
Tachypnoea
(>20/min)
Urinary flow
rate (ml/h)
>30
20-30
10-20
0-10
Extremities
Colour normal
Pale
Pale
Pale and cold
Complexion
Normal
Pale
Pale
Ashen
Mental state
Alert
Anxious or
aggressive
Anxious,
aggressive,
or drowsy
Drowsy,
confused,
or unconscious
ii.
Peri-operative transfusion
Wherever possible, the objective should be to manage the patient so that
transfusion of allogeneic blood is not required.
Pre-operative considerations:
The Optimum Surgical Blood Order Schedule (OSBOS) should be used for
patients undergoing surgery that would normally require blood transfusion.
Patients should have a full blood count and group & antibody screen
performed when placed on the waiting list for elective surgical procedure that is
NP001 – Blood Transfusion Policy
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Page 32 of 49
likely to require red cell transfusion (See Optimum Surgical Blood Ordering
Schedules).
Patients with microcytic anaemia should be investigated for iron deficiency.
Iron deficiency anaemia should be corrected during the pre-operative period.
Stop aspirin or other antiplatelet therapy one week pre-operatively
possible.
where
Pro-active management of anticoagulated patients.
Consider alternatives to allogeneic blood wherever appropriate:
Consider Peri-operative red cell salvage where relevant (anticipated blood loss
= / > 1 Litre and no contraindication such as malignancy or contaminated field).
The cell salvage machines are now available in theatres at all three sites and
the majority of ODPs have been trained in their use.
Autologous pre-deposit, where appropriate, can reduce the need for allogeneic
red cells. Contact blood bank for further information.
Acute normovolaemic haemodilution is another option that may be considered
for suitable patients.
Peri-operative red cell transfusion triggers:
Decision to transfuse should based on assessment of clinical and laboratory
parameters.
Hb 10 g/dL or above – normally no red cell transfusion required.
Hb less than 7 g/dL, no further blood loss anticipated – transfuse 2 units of red
cells. Aim to maintain Hb at 8-9 g/dL. In the elderly and in patients with
ischaemic heart disease, maintain Hb 9-10 g/dL.
Hb 7-8 g/dL, in a patient who is otherwise stable and no further blood loss is
anticipated, is not normally an indication for transfusion unless the patient is
clearly symptomatic of anaemia.
iii.
Anaemia in critical care
Over transfusion may increase mortality in this group.
a) Herbert et al 1999 – Canadian Critical Care Trial Group, randomised,
controlled (n=838) NEJM, 340, 409-417.
b) Vincent JL et al, Sep 2002 – Western European, multi-centre, prospective
observational study (n= 3543)- JAMA 2002; 288: 1499-507.
NP001 – Blood Transfusion Policy
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Decision to transfuse should based on assessment of clinical and laboratory
parameters.
Hb 10 g/dL or above – normally no red cell transfusion required.
Hb less than 7 g/dL, no further blood loss anticipated – transfuse 2 units of red
cells. Aim to maintain Hb at 8-9 g/dL. In the elderly and in patients with
ischaemic heart disease, maintain Hb 9-10 g/dL.
Hb 7-8 g/dL, in a patient who is otherwise stable and no further blood loss is
anticipated, is not in itself an indication for transfusion.
iv.
Chronic anaemia
In patients without significant symptoms of anaemia, avoid transfusion and
establish underlying cause.
Investigate and treat haematinic deficiency.
Consider erythropoietin (e.g. in anaemia associated with chronic renal failure).
v.
Anaemia associated with malignancy
Currently, there is no consensus on transfusion triggers in patients with
anaemia associated with haematological or non-haematological malignancy.
In patients with haematological malignancy, the majority practice in the UK is
aimed at maintaining Hb levels around 10 g/dL.
References
1.
2.
3.
4.
5.
6.
British Committee for Standards in Haematology, Blood Transfusion Task
Force (2001) Guidelines for clinical use of red cell transfusions. British Journal
of Haematology. 113, 24-31. (www.bcshguidelines.com).
The Association of Anaesthetists of Great Britain and Ireland (Sep 2001) Blood
Transfusion and the Anaesthetist – Red cell Transfusions. (www.aagbi.org).
Serious Hazards of Transfusion, Annual Reports 1996-2001.
(www.shotuk.org).
Handbook of Transfusion Medicine, 3rd ed. (2001). The Stationary Office.
Access to full text available on www.transfusionguidelines.org
Mortimer P. Making Blood Safer. BMJ 2002;325:400-1
Department of Health, Better Blood Transfusion-Health Services Circular (HSC
009/2002) www.doh.gov.uk/bbt2
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 34 of 49
APPENDIX 4 THE UHL GUIDELINES FOR THE USE OF PLATELETS
These guidelines are based on the current national guidelines by the British
Committee on Standards in Haematology (BCSH), published in July 2003.
(British Journal of Haematology 2003; 122, 10-23)
Standard Single dose:
Adults: 1 adult therapeutic dose (ATD)
Clinical indications for platelet transfusions
•
Platelet transfusions are indicated for the prevention and treatment of
haemorrhage in patients with thrombocytopenia or platelet function defects.
•
Platelet transfusions are not indicated in all causes of thrombocytopenia and
may indeed be contraindicated in certain conditions.
•
The cause of thrombocytopenia should be established (where possible) before
a decision about the use of platelet transfusion is made.
•
Any decision must also be based on an assessment of risk versus benefit.
Risks associated with platelet transfusions include alloimmunization,
transmission of infection, allergic reactions and transfusion-related acute lung
injury; potential benefits include reducing morbidity associated with minor
haemorrhage and reducing morbidity/mortality resulting from major bleeding.
Bone marrow failure (due to disease, cytotoxic therapy or irradiation)
Therapeutic platelet transfusions are indicated for patients with active bleeding
associated with thrombocytopenia, although serious spontaneous haemorrhage due
to thrombocytopenia alone is unlikely to occur at platelet counts above 10 109/L.
Prophylactic platelet transfusions have become standard practice for patients with
bone marrow failure.
1. Acute leukaemia (excluding promyelocytic leukaemia)
A threshold for prophylactic platelet transfusion of 10 x 109/L should be used,
unless severe sepsis &/or minor haemorrhage warrants a higher threshold of
20 x 109/L.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 35 of 49
2. Acute promyelocytic leukaemia
There are no studies that specifically address the threshold for platelet
transfusion in this condition. The presence of a coagulopathy would be
expected to increase the likelihood of haemorrhage at any given platelet count.
As a minimum, the platelet count should be kept above 30 109/L in patients
who are haemorrhagic and until coagulopathy is completely resolved.
3. Haemopoietic stem cell transplantation
The risk of mucosal injury is generally higher in bone marrow transplantation
than with chemotherapy for acute leukaemia. However, a small number of
studies have indicated that the threshold for platelet transfusion can again be
safely lowered to 10 109/L .
Peripheral blood stem cell transplantation results in a shorter duration of
thrombocytopenia than bone marrow transplantation, and the threshold for
platelet transfusion can be the same as for marrow transplantation and acute
leukaemia.
3. Chronic stable thrombocytopenia
Patients with chronic and sustained failure of platelet production, for example
some patients with myelodysplasia or aplastic anaemia, may remain free of
serious haemorrhage with platelet counts consistently below 10 109/L.
A specific threshold for transfusion is not appropriate for patients with
chronic stable thrombocytopenia and these patients are best managed
on an individual basis depending on the degree of haemorrhage.
Long-term prophylactic platelet transfusions may be best avoided in these
patients because of the risk of alloimmunization and platelet refractoriness,
and other complications of transfusion.
Therapeutic platelet transfusions should be used to treat overt haemorrhage,
and such patients may require prophylactic platelet transfusions to prevent
recurrent haemorrhage during unstable periods associated with infection or
active treatment.
Prophylaxis for surgery and invasive procedures
If platelet transfusion is necessary to raise platelet count to cover an invasive
procedure, it must not be assumed that the platelet count will rise just because
platelet transfusions are given.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 36 of 49
A preoperative platelet count should always be checked to ensure that the following
thresholds have been reached.
Bone marrow biopsy:
In patients with severe thrombocytopenia, who are not haemorrhagic and who do not
have coagulopathy, bone marrow aspiration and trephine biopsy may be performed
without platelet support, providing that adequate surface pressure is applied.
In the presence of haemorrhagic symptoms or coagulopathy, the platelet count
should be raised to at least 30 x 10 9/L for bone marrow trephine biopsy.
Other invasive procedures:
For lumbar puncture, epidural anaesthesia, gastroscopy and biopsy, insertion of
indwelling lines, transbronchial biopsy, liver biopsy or similar procedures, the platelet
count should be raised to at least 50 109/L.
Major Surgery:
For laparotomy, multiple trauma surgery, major cardio-thoracic surgery and
operations in critical sites such as the brain or eyes, the platelet count should be
raised to 100 109/L.
Platelet function disorders
Patients with platelet function disorders rarely need platelet transfusions.
However, acquired causes of platelet dysfunction can exacerbate bleeding in patients
who already have impaired haemostasis.
The following recommendations (grade C, level IV) are for the management of
bleeding or for prophylaxis before invasive procedures for patients with a known or
suspected platelet function disorder. It is no longer considered necessary to use HLAmatched platelet transfusions for non-alloimmunized patients.
•
•
•
•
•
•
Withdraw drugs known to have antiplatelet activity.
Correct any underlying condition known to be associated with platelet
dysfunction, if possible.
Correct the haematocrit to > 0·30 l/l in patients with renal failure, either with the
use of recombinant erythropoietin or red cell transfusion.
Consider the use of DDAVP (1-deamino-8-D-arginine vasopressin,
desmopressin) in patients with inherited dysfunction defects, such as storage
pool disease.
Consider the use of DDAVP or cryoprecipitate in patients with uraemia.
Use platelet transfusions where the above methods are not appropriate or are
ineffective.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 37 of 49
•
Recombinant factor VIIa, has been shown to be effective in the management
of bleeding and for prophylaxis before surgery in patients with Glanzmann's
thrombasthenia
Massive Transfusion
A platelet count of around 50 109/l is expected when red cell concentrates
equivalent to approximately two blood volumes have been transfused.
There is consensus that the platelet count should not be allowed to fall below 50
109/l in patients with acute bleeding
A higher target level of 100 109/l has been recommended for those with multiple
trauma or central nervous system injury.
Please refer to the UHL massive haemorrhage protocol.
Disseminated Intravascular Coagulation (DIC)
Platelet transfusions are a part of the management of acute DIC, where there is
bleeding associated with thrombocytopenia, in addition to management of the
underlying disorder and coagulation factor replacement.
Frequent estimation of the platelet count and coagulation screening tests should be
carried out.
aim to maintain the platelet count > 50
109/l, as in massive blood loss
In chronic DIC, or in the absence of bleeding, platelet transfusions should not be
given merely to correct a low platelet count.
Cardiopulmonary bypass (CPB)
Where possible, consider stopping anti-platelet drugs at least a week pre-op in
patients attending for elective surgical revascularization.
Where it is not safe or possible to discontinue anti-platelet drugs before surgery,
consider using aprotonin.
Microvascular bleeding, as indicated by continued oozing from surgical incisions and
venous cannulation sites, may occur as a consequence of either thrombocytopenia
(usually platelet counts < 50 109/l) or acquired (transient, reversible) platelet
dysfunction due to CPB.
The use of the thromboelastograph (TEG) has been found to help the decisionmaking process about appropriate platelet transfusion in some institutions.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 38 of 49
The use of platelet transfusion should be reserved for those patients who are
experiencing excessive postoperative bleeding and in whom a surgical cause has
been excluded.
There is no indication for prophylactic transfusion of platelets in patients undergoing
CPB.
Post-transfusion purpura
High-dose intravenous immunoglobulin (2 g/kg given over 2 or 5 d) is the current
treatment of choice and has 85% response rate.
High dose ( 2 or more adult doses) platelet transfusions may be required to control
severe bleeding before there has been a response to high-dose intravenous
immunoglobulins.
There is no evidence that platelet concentrates from HPA-1a-negative platelets are
more effective than those from random donors in the acute thrombocytopenic phase,
and the dose of platelets may be more important than the type of the donor platelets.
It is not known whether random transfusions in the acute phase prolong the duration
or severity of thrombocytopenia.
Autoimmune thrombocytopenia (ITP)
Platelet transfusions are generally ineffective in ITP and are reserved for patients
with life-threatening bleeding from the gastrointestinal or genitourinary tracts, bleeding
into the central nervous system or other sites associated with severe
thrombocytopenia.
In these situations, intravenous methylprednisolone 500 mg to 1 g (adult dose) and /
or high dose IV immunoglobulins (1 g/Kg body weight /day for 2 days) should be
given at the same time to maximize the chances of stopping the haemorrhage and
raising the platelet count.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 39 of 49
LEICESTERSHIRE COUNTY AND RUTLAND PRIMARY CARE TRUST
BLOOD TRANSFUSION AUDIT TOOL
STATEMENT
AUDIT CRITERIA
COMMENTS
1. The patient received a
Blood Transfusion
leaflet prior to the
Blood Transfusion
1.1 It is documented in the patient nursing notes that they received a blood transfusion
information
booklet
1.2 There is access to patient information leaflets in the ward areas that carry out blood
transfusions and in OPD
1.3 Patient consent is recorded in notes.
2. It is clearly
documented for the
need for transfusion
2.1 The reasons for transfusion are clearly documented in the patients medical notes
3. To reduce wastage of
blood products
3.1 Patent venous access is established prior to collection of unit of blood and documented
(check cannulation documentation)
4. The giving sets used
are specifically for the
administration of
blood and blood
products.
4.1 The correct giving sets are in place in the clinical area
4.2 It is documented that the giving set has been changed every 12 hours in the patient notes
4.3 Blood giving sets on the wards are within expiry dates
5. The Blood Component
Prescription and
Administration Chart
is completed correctly
5.1Patient name
5.2 Address
5.3 Hospital No/NHS no
5.4 Date of Birth
5.5 Date of prescription is completed
5.6 Blood Component is clearly identified
5.7 Dose/ Volume is entered
5.8 CNV Neg / irradiated/ HLA matched or not applicable
5.9 Rate of infusion
5.10
Other specific instructions identified
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 41 of 49
STATEMENT
AUDIT CRITERIA
COMMENTS
5.11 Dr.’s signature and initial in place
5.12 Nursing check signed and initialled
5.13 Administering nurse signed and initialled
5.14 Start time of blood transfusion recorded
5.15 End time of blood transfusion recorded
6. The patient is
correctly monitored
during the transfusion
6.1 BP, Temp and Pulse are recorded on the Blood Component Prescription and
Administration Chart
6.2 Pre transfusion observation recorded
6.3 Observations recorded at 20 minutes
6.4 Observations recorded at 60 minutes
6.5 Observations recorded on the early warning chart for each subsequent hour and completion
of blood transfusion
6.6 Observations increased if abnormality noted
6.7 It is documented in the patient’s notes whether the patient has / has not shown signs of
reaction.
6.8 The management and investigation of any reaction is clearly documented with actions
taken
6.9 The end time of the transfusion is recorded
6.10
7. Management of
reactions will be in
line with policy
The patients evaluation shows:
7.1 Whether patient experienced a reaction, and gives account of presentation, signs and
symptoms
7.2 Haematology department informed
7.3 Medic informed
7.4 Blood transfusion stopped
7.5 Clear advice from haematologist and medic documented
7.6 Instructions requested and carried out
7.7 ARF1 form completed
7.8 Condition of patient documented
7.9 Patient observations completed
Name of Auditor: ……………………………...………………. Sig:………………………………………………….
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 42 of 49
AUDIT RESULTS TABLE.
LOCATION: ……………………………………………………………………………. WARD: ……………………………………………………………
No of record
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
1.1
1.2
1.3
2.1
3.1
3.4
3.5
4.1
4.2
4.3
5.1
5.2
5.3
5.4
5.5
5.6
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 43 of 49
19
20
21
22
23
24
25
Yes
No
N/a
No of record
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
5.7
5.8
5.9
5.10
5.11
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
7.1
7.2
7.3
7.4
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 44 of 49
19
20
21
22
23
24
25
Yes
No
N/a
No of record
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
7.5
7.6
7.7
7.8
7.9
Comment
Actual % score = ……………………………………………………
(No of Yes divided by total no of applicable responses x 100)
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 45 of 49
19
20
21
22
23
24
25
Yes
No
LEICESTERSHIRE COUNTY AND RUTLAND PRIMARY CARE TRUST
BLOOD FRIDGE AUDIT
STATEMENT
1. Daily checks are performed and
recorded to ensure that fridge is in
good working order.
AUDIT CRITERIA
1.1
1.2
1.3
1.4
1.5
COMMENTS
Fridge is clean and tidy
Fridge is dust free
Temperature reads 4 oC
Only blood is present in fridge
There is a separate log book has evidence of daily checks
and recording of fridge temperature
Receiving blood into fridge
2. Documentation is complete in all
sections showing a clear pathway of
blood components stored within the
fridge
2.1 Log book is in place for receipt and removal of blood
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
components
Date blood is received is recorded
Time of blood received is recorded
Patient name recorded
NHS number is recorded
Hospital/ ward recorded
Unit bag number recorded separately
Unit expiry date recorded separately
Receivers signature present
Removal of blood for patient transfusion
2.10
2.11
2.12
2.13
2.14
2.15
2.16
Date blood removed
Time blood removed
Patient name recorded
NHS number recorded
Ward recorded
Unit bag number recorded
Signature of person removing unit
AUDIT RESULTS TABLE.
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 46 of 49
LOCATION: ……………………………………………………………………………. WARD: ……………………………………………………
No of
record
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
1.1
1.2
1.3
1.4
1.5
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 47 of 49
20
21
22
23
24
25
Yes
No
No of
record
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
Comments
Actual % score = ……………………………………………………
(No of Yes divided by total no of applicable responses x 100)
NP001 – Blood Transfusion Policy
Status – Final, Approved November 2007
Review Date; November 2009
Nursing and Quality Directorate
Page 48 of 49
20
21
22
23
24
25
Yes
No
Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group
less or more favourably than another on the
basis of:
• Race
No
• Ethnic origins (including gypsies and
travellers)
No
• Nationality
No
• Gender
No
• Culture
No
• Religion or belief
No
• Sexual orientation including lesbian, gay
and bisexual people
No
• Age
No
2.
Is there any evidence that some groups are
affected differently?
No
3.
If you have identified potential
discrimination, are any exceptions valid,
legal and/or justifiable?
N/A
4.
Is the impact of the policy/guidance likely to
be negative?
No
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking
different action?
N/A
If you have identified a potential discriminatory impact of this procedural document, please
refer it to the Policy Administrator, together with any suggestions as to the action required
to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Policy
Administrator.