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Blood transfusion

Introduction

  • Wash hands; Introduce self; ask Patient’s name, DOB and check wristband; Explain:
    • Reason for transfusion
    • Benefits 
    • Risks
      • Viral infections (HIV: 1 in 6.5 million; hepatitis B: 1 in 1.3 million; hepatitis C: 1 in 28 million; variant Creutzfeldt-Jakob disease: 4 isolated cases)
      • Bacterial infection (contamination)
      • Transfusion reactions
    • Will never be able to donate blood again
  • Gain consent

Indications for red cell concentrates

  • Haemoglobin <70 g/L (or <80g/L if elderly/cardiovascular/respiratory disease)
  • Significant blood loss (>1.5L or >30% blood volume)
  • Symptomatic anaemia (myocardial ischemia, orthostatic hypotension or tachycardia)
  • Acute sickle cell crisis (stroke prevention)

Indications for platelet concentrate

  • Platelets <10×109/L in bone marrow failure (or <20 x109/L if septic)
  • Platelets <50×109/L if undergoing surgery or actively bleeding (<100×109/L if multiple trauma/spontaneous intracerebral haemorrhage/ neurosurgery/posterior ophthalmic surgery)
  • Acquired/inherited platelet dysfunction (but not TTP/HUS/HIT)
  • Disseminated intravascular coagulation + haemorrhage
  • Other rarer platelet disorders

Indications for fresh frozen plasma (FFP)

  • Disseminated intravascular coagulation + haemorrhage 
  • Massive haemorrhage
  • Coagulation factor replacement (if specific factor concentrate unavailable)
  • Immediate warfarin reversal (if prothrombin complex concentrate not available)
  • Liver disease-related bleeding

Indications for cryoprecipitate

Used if fibrinogen is low (<1g/L) and there is active bleeding, e.g. in:

  • Disseminated intravascular coagulation
  • Liver disease 

Indications for CMV seronegative components

Used for patients at risk of severe CMV disease:

  • Pregnant women
  • Neonates/intrauterine transfusions

Indications for irradiated components

Used to prevent transfusion-associated graft vs. host disease in severely immunocompromised:

  • Severe T-cell immunodeficiency syndromes
  • Hodgkin lymphoma (current/past)
  • Bone marrow or stem cell transplant recipients
  • Patients who have ever had purine analogues or anti-T cell monoclonal antibodies
  • Directed donations from families
  • Exchange transfusions
  • Neonates/intrauterine transfusions

Requesting blood products

  • Take a blood sample (pink tube) and fill in all details by hand at patient’s bedside (cross-referencing with the patient and their wristband)
  • Complete a blood transfusion crossmatch request form 
  • Include all details:
    • Patient (full name, DOB, sex, hospital number, address/NHS number)
    • Transfusion (indication, Hb if known, blood product required, number of units, special requirements, e.g. CMV negative or irradiated)
    • Doctor (name, signature)
    • Date and ward
  • Send the form with the blood tube to the haematology laboratory
  • Complete a blood transfusion prescription form (each unit prescribed separately)
    • Demographic details
    • Units prescribed
    • Infusion rate:
      • Packed red cells: normally 1 unit over 2-3 hours (maximum 4 hours)
      • Fresh frozen plasma (FFP): 30 minutes
      • Platelet concentrate: 30 minutes
      • Cryoprecipitate: 30 minutes
  • Consider prescribing 40mg furosemide IV/PO with each/every other unit if patient is at risk of fluid overload

NB: in an emergency, there will not be time to crossmatch blood, so O negative (or non-crossmatched group-specific blood) may be used.

Setting up the blood transfusion

  • Follow the notes on administering an intravenous infusion p218
  • Additionally you must:
    • Check the blood unit
      • Any leaks
      • Any haemolysis (pink plasma)
      • Any clots
      • Red colour
    • With a colleague, check the details on the blood unit against the following:
      • Transfusion slip
      • Patient
      • Patient’s wristband
    • Route the giving set line through a blood-warmer if patient has undergone surgery, has cold agglutinins, requires rapid large volume transfusion, or exchange transfusion
    • Request nursing observations at 0, 15, 30 minutes and then hourly, and at the end of the transfusion. Ask to be informed of any problems.
    • Document in notes

Follow-up

  • Consider taking a post-transfusion blood sample
    • Red cell concentrates: FBC 6 hours after or the next day. NB: one unit should increase haemoglobin concentration by approximately 10g/L.
    • Platelet concentrates: FBC 30 minutes after. NB: one transfusion should increase platelet count by 30-60×109/L.
    • FFP: coagulation screen 30 minutes after

Blood transfusion reactions

  • Most transfusion reactions occur within 15 minutes
  • For all reactions (except febrile reaction), STOP the transfusion, maintain IV access with saline and call consultant haematologist
  • Consider: 
    • FBC, U&Es, lactate dehydrogenase, repeat compatibility testing, direct antiglobulin test, serum haptoglobin coagulation screen and D-dimer (for disseminated intravascular coagulation)
    • Blood cultures
    • Venous blood gas

Types of transfusion reaction

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