Blood transfusion

Please note this information is for educational purposes only and procedures should not conducted based on this information. OSCEstop and authors take no responsibility for errors or for the use of any content.

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 (e.g. >1.5L or >30% blood volume)
• Symptomatic anaemia (myocardial ischemia, orthostatic hypotension or tachycardia)

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