Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Guidelines for care of a patient receiving a red blood cell transfusion whilst undergoing extra corporeal therapies. Contact Name and Job Title (author) Directorate & Speciality Belinda Dring and Kate Taylor. Anaemia Nurse Specialists and leads for Anaemia Management ext:55171 DIRC; Renal and Transplant Date of submission 1 st January 2016 Date on which guideline must be reviewed (this should be one to three years) Inclusion Criteria Exclusion Criteria Version 3.0 Abstract 1 st January 2019 All patients under the care of the Nottingham renal and Transplant Unit, including patients at the Dialysis Units at Lings Bar, Kings Mill Hospital, Sutton in Ashfield and Shipley Dialysis Unit, Ilkeston. Patients undergoing Plasma exchange This guideline describes the care required for a patient receiving a red blood cell transfusion whilst undergoing extra corporeal therapies. Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Haemodialysis, Haemodiafiltration,HD, HDF, SLED, blood on dialysis Evidence base 1 for prescription of red cells and 6 for administration. These guidelines were peer reviewed by Senior Nursing, Medical and Pharmaceutical Staff within the Renal and Transplant Unit and ratified at the Renal Senior Staff Meeting Patients undergoing Haemodialysis (HD), Haemodiafiltration (HDF) and Slow Low efficiency dialysis (SLED) 1 of 6
1. Evidence base: These guidelines have been derived using the following evidence base. National Collaborating Centre for Chronic Conditions, Royal College of Physicians (2015) Anaemia Management in people with chronic kidney disease. National Institute for Health and Clinical Excellence (NICE). The British Committee for Standards in Haematology (BCSH) guidelines. www.bcshguidelines.com Nottingham University Hospitals NHS Trust, Administration of Blood & Blood Components Procedure (2014) British Renal Association Guidelines for the management of Chronic Kidney Disease in adults (2010) Standards and Audit Subcommittee of the Renal Association on behalf of the Renal Association and the Royal College of Physicians of London, in collaboration with the British Transplantation Society, the Intensive Care Society, and the British Association of Paediatric Nephrologists. 2. Introduction The use of erythropoietin stimulating agents (ESA) has reduced the need for Blood Transfusion within the renal population (MacDougall, 2003, NICE 2011). However in certain situations a blood transfusion is indicated, these include: The severely anaemic patient with recognised symptoms or signs due to anaemia, e.g., the patient with acute blood loss associated with haemodynamic instability. The ESA resistant patient with or without chronic blood loss. In people with anaemia of CKD in whom kidney transplant is a treatment option, blood should be avoided where possible. In people with anaemia of CKD, there may be situations where a transfusion is indicated clinically. In these cases, the relevant haematology guidelines should be followed. 2 of 6
3. Prescription of Red Cell Concentrate (Blood) Prescription of blood should be undertaken by medical practitioners who have completed the relevant blood transfusion training package. Prescription should be undertaken in accordance with the NUH Guideline for the appropriate use of blood and blood components. In particular medical staff should generally follow a restrictive transfusion strategy. A dose of 4ml/kg raises the Hb concentration by approximately 10 g/l in adults. The notion of 1 bag raising the Hb by 10 g/l is ONLY applicable to adults of 70 kg in weight. There is no universal trigger or target haemoglobin for transfusion. Situations when a red cell transfusion should be considered include: Active blood loss Hb <70g/L Hb <80g/L for symptomatic patients with cardiovascular disease For patients who are not actively bleeding, in general single unit transfusions should be given and the Hb rechecked. Each transfusion should be an independent clinical decision based on the risk, benefits and alternatives. The reassessment of patients must include a clinical review to identify signs and symptoms of anaemia and a repeat Hb measurement, if required. Patients with chronic transfusion dependent anaemia may require an alternative administration schedule where 2 units of blood are transfused. 4. General Information 1. This procedure is to be carried out by a registered nurse, competent in extra corporeal therapies and used in conjunction with the Nottingham University Hospitals NHS Trust Administration of Blood & Blood Components Procedure (2014). 2. For details of the correct procedures regarding the issuing and collection of red cell products from blood bank and checking procedure with patient, please refer to the Nottingham university Hospital NHS Administration of Blood & Blood Components Procedure (2014). 3. Care must be taken to avoid both hypervolaemia and hyperkalaemia as a consequence of transfusion. 3 of 6
5. Administration of Blood Positive Patient ID MUST be completed before any administration of blood. 1. Blood must be administered using a designated blood administration set which has a filter of 200mm unless otherwise instructed in the compatibility form. 2. The amount of blood units able to be transfused through one administration set is also subject to manufacturer s guidance, although usually, this is two units per administration set. 3. Gloves and apron should be worn whilst attaching the blood to the administration set. 4. Wash hands; connect administration set to blood transfusion bag, according to the procedure for the procedure for the preparation of an intravenous infusion and care of a patient receiving an intravenous infusion (see Nottingham nurse procedure and guideline file). 5. Blood administration set to be connected to the fluid administration port on the arterial line of the extra corporeal circuit, via a Y connector. Ensure 0.9% Saline plus giving set is connected to other lumen of Y connector (clamped). This ensures blood is administered pre-dialyser, then enables blood to be dialysed prior to infusion to patient. 6. If multiple venous access is present, ensure that blood is not administered at the same time as any other drug likely to also cause an anaphylactic reaction / drug interaction. 6. Rate of Administration 1. If a period of isolated ultra filtration is required, this must be undertaken prior to the commencement of the blood transfusion. 2. Unless requested by medical staff, no more than two units of red blood cells should be administered during one HD/HDF session. 3. The dialysis fluid temperature enables the infused blood to be warmed and therefore allows a more rapid rate of infusion therefore blood can be administered at a rate no faster than 30 minutes per unit. 4. Administration is via continuous infusion. Continuous infusion is preferred over bolus administration to prevent oversight of transfusion, and increased risk of patient infection due to delayed administration. 4 of 6
7. Observation 1. The nurse should remain with the patient for the first 5 minutes after each unit of blood is commenced as severe reactions can occur during the first 1-5 minutes of transfusion. 2. Full set of Observations should be performed and recorded on the observation sheets; 30-60minutes prior to the start of the unit before the unit is collected, 15 minutes after the start of the transfusion and at the end of the transfusion as long as the patient does not report any adverse effects during the transfusion. The transfusion observations are in addition to any other observation schedule the patient is on. The patient should be asked to inform the nurse if they feel at all different during the transfusion. This is the same for each unit of blood commenced. 3. Further observations during the transfusion of each unit need only be taken should the patient become unwell or show signs of transfusion reaction. Visual observation of the patient is often the best way of assessing patients during transfusion. 4. Full set of observations MUST be measured on completion of each unit, along with the finish time for that transfusion; this becomes the baseline for the patient post transfusion. A patient should be monitored for signs of a transfusion for 24 hours post the transfusion episode. Please ask the patient to contact the Dialysis Unit / Carrel ward if they feel unwell post dialysis at home. 5. Unconscious patients are less easy to monitor for possible reaction and as a result frequent observation patterns should be maintained, according to the patient s condition. 6. During the transfusion observe the patient for signs of flushing; itching; fever; vomiting; diarrhoea; rigor; backache; haemoglobinuria; collapse and circulatory failure. If any of these occur the transfusion should be stopped and a member of the medical staff should be contacted immediately. Please see Recognition and Management of Transfusion Reactions Procedure, 2013: CL/CGP/083 (pages 12-16 shows the procedure to follow) 7. Further management depends on the reaction and maybe suggested by the medical staff. 8. If the decision is to stop the transfusion, disconnect the administration set immediately and withdraw blood (approx 2mls) from the venous access device as 5 of 6
this prevents further transfused blood from entering the patient s circulation. The patient s full set of observations including EWSMUST be recorded. 9. If a severe reaction is suspected this should be reported to the hospital s blood bank as per trust policy and an incident report form completed. The blood administration set should be changed and venous access must be maintained. The reaction should be reported immediately to the blood bank, which will request the return of the implicated unit and further blood samples from the patient. 10. The blood unit and administration set should be transported back to blood bank using a waterproof container e.g. empty unsealed sharps bin or placenta bin. 8. Post Transfusion 1. Once blood transfusion is completed dialysis can be discontinued as planned as the blood has already been dialysed prior to infusion and hence will not significantly increase serum potassium levels post transfusion. 2. Do not disconnect last administered blood bag from giving set or flush with saline. Empty blood bag should be discarded with all extra corporeal lines on completion of dialysis according to hospital policy for the disposal of clinical waste. 3. The blood transfusion MUST be documented on the Transfusion Record Sheet as well as on the renal IT system (including completion of the transfusion module in emed Renal). The top copy of the transfusion record sheet MUST be returned to the Transfusion Practitioner Team. 4. Any components or products issued by the laboratory must be documented on the transfusion record sheet as proof of transfusion to comply with Blood Safety and Quality Regulations (EU Law 2005). 5. Any unused Human Albumin Solution MUST be returned to the laboratory and not kept on the ward. 6. Any wasted units please inform the Blood Transfusion Laboratory and complete a DATIX Incident. 6 of 6
9. References / Suggested reading Audet A.M., Goodnough L.T. (1992) Practice strategies for elective red blood transfusion. Ann Intern Med 116:403-406. Chapman J.F., Elliott C., Knowles S.M., Milkins C.E. and Poole G.D. (2004). Guidelines for compatibility procedures in blood transfusion laboratories. Working Party of the British Committee for Standards in Haematology Blood Transfusion Task Force. Transfusion Medicine, 2004, 14, 59 73 Department of Health (2004) The National Service Framework for Renal Services. Part One: Dialysis and Transplantation. HMSO. London. K/DOQI (2006) Clinical Practice Guidelines for the treatment of Anaemia in Chronic Renal Failure. National Kidney Federation. New York. Dr Derek Norfolk (2013) (Handbook of Transfusion Medicine. 5 th Transfusion Service of the United Kingdom. The Stationery Office Books. Edition. MacDougall I.C. (2003) CREATE: New strategies for early anaemia management in renal insufficiency. Nephrology, Dialysis and Transplantation. No18. Supplement 2. Page 12-16. NICE (2015) Anaemia Management in Chronic Kidney Disease CG8. National Institute for Clinical excellence available at http://guidance.nice.org.uk/cg8 Nottingham University Hospital NHS Trust, Administration of Blood & Blood Components Procedure (2014) Nottingham University Hospital Transfusion Policy 2014, CL/CGP/008 NPSA Safer Practise Notice 14: Right Blood, Right Patient: advice for safe transfusion Practice www.nrls.npsa.nhs.uk/resources/collections/right-patientright-blood Renal association (2010) Clinical practice guidelines Anaemia in CKD available at http://www.renal.org/libraries/guidelines/anaemia_in_ckd_final_draft_version _-_20_July_2010.sflb.ashx SHOT Annual Report Shotuk.com 7 of 6
Recognition and Management of Transfusion Reactions Procedure, 2013: CL/CGP/083 (pages 12-16 shows the procedure to follow) 8 of 6