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)

Platelet concentrates

• 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

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

Cryoprecipitate

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

• Disseminated intravascular coagulation
• Liver disease

When you need to request…

CMV seronegative components

Used for patients at risk of severe CMV disease:

• Pregnant women
• Neonates/intrauterine transfusions

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
• 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