Blood Bank Instructions

Blood Bank Instructions Blood Bank Transfusion Services Available at MidMichigan Laboratories-Clare, MidMichigan Laboratories-Gladwin, MidMichigan Laboratories-Gratiot, and MidMichigan Laboratories-Midland Components/Services Available Component Clare Gladwin Gratiot Midland Notes Red cells N/A N/A N/A N/A All affiliates leuko-reduced Leuko-reduced red cells X X X X Whole blood N/A N/A N/A N/A Fresh frozen plasma X X X X 30 minutes thawing time Cryoprecipitate Supplier X X X 30 minutes thawing time Leukocytes Supplier Supplier Supplier Supplier Platelets, random Supplier Supplier Supplier Supplier 2 to 4 hours for delivery Platelets, pheresis Supplier Supplier Supplier Supplier 2 to 4 hours for delivery Autologous Ernie Supplier Supplier Supplier donation Wallace By appointment Directed Red cells Supplier Supplier Supplier Supplier Requires physician request RhoGAM Available at Wackerly Laboratory, POB Laboratory, and Mount X Pharmacy X X Pleasant Health Park Monday through Friday 8 a.m. to 4 p.m. Therapeutic phlebotomy Nursing Nursing Nursing Therapeutic apheresis Infusion Center Davita Davita Davita By appointment By appointment Michigan Blood is the Supplier for Clare, Gladwin, Gratiot and Midland. Michigan Blood is located in Saginaw.

Ordering Components You may order components using a variety of methods: You can place an order in Hospital Information System (HIS). This order is electronically sent to the Blood Bank where it will be processed. Once processed, it is placed on a collection list to be drawn according to priority. You can place an order into LIS (Laboratory Information System). This order is automatically routed to a collection list. You can send a laboratory downtime request to laboratory. Laboratory staff will place order into LIS where it will be routed to a collection list. Release of Components from Blood Bank When Nursing Unit is ready for component to be issued, they should initiate process by calling laboratory to inform them that a request is forthcoming. Nursing station must then send (or bring) to the Blood Bank an addressographed or handprinted request containing: Patient name Medical record number Amount and type of component requested Current patient location In Clare, Gladwin and Gratiot nursing unit staff present to the blood bank for unit release. In Midland units will be sent via pneumatic tube. If tube system is not available, the Nursing Unit must request that Transportation Department come to Blood Bank with appropriate request form for desired components. Administration of Blood and Blood Components When blood arrives at nursing station, identify recipient and donor unit: Accurate identification of donor s blood and intended recipient may be the single most important step in ensuring transfusion safety. Most fatal hemolytic transfusion reactions occur because ABO-incompatible RBCs were inadvertently administered. Plasma, platelets, and blood derivatives are also capable of causing serious transfusion reactions. Only a physician may order blood or blood products. Before sending for ordered blood, physician or nurse must start an intravenous (IV) with a Y-type or straight infusion set with filter. These sets are available in Supply/Distribution and should be stocked on all floors. Y-type administration set is used for alternating administration of blood and compatible intravenous solution, not for their simultaneous administration. When using Y-type set, 1 container must be shut off at all times. Except for patients who are fluid restricted, 50 ml to 100 ml of 0.9% saline solution can be transferred directly into a red blood cell container to decrease viscosity and increase flow rate. NO OTHER DILUENT IS ALLOWED. When multiple units are administered serially, IV administration set must be replaced by a new sterile set every 24 hours or after 6 units of blood have been filtered. Not all IV solutions are suitable for use with blood in a Y-type administration set, since some of those commonly used are not compatible with blood. Isotonic saline (0.9% solution) is completely compatible with blood. Recent work has shown that 5% dextrose in 0.25% saline will cause agglutination of red cells. Five percent dextrose in water will hemolyzed blood and must never be used. IV solutions containing calcium, such as lactated Ringer s, are prohibited because they can cause clotting on mixing with blood. All drugs, anesthetic agents, muscle relaxants, or vitamins may injure red cells and must never be added to blood. Blood Bank personnel will notify Nursing Unit by phone when ordered blood is ready. In Midland, units of blood may be transported via the pneumatic tube or by nursing staff at Clare, Gladwin and Gratiot. Only 1 unit of blood will ordinarily be issued at 1 time for any patient, unless more than 1 IV infusion has been started on that patient. (This does not apply to RhIG, platelets, or cryo.) Please notify Blood Bank if more than 1 unit of blood is needed at a time to avoid unnecessary delays. Only nursing personnel or physicians may accept blood or blood components on patient unit. When blood arrives on the floor, record the time of receipt on the unit tie tag. Document that the component is for intended recipient. Blood must not be stored in patient unit refrigerators, since a constant required temperature of 1 C to 6 C is not maintained. These refrigerators are not monitored. If unit of blood cannot be infused shortly after being received from Blood Bank, nurse should not accept delivery. An unused unit of blood MUST be returned to Blood Bank within 30 minutes of issue or it must be discarded. The cost of a wasted unit may be charged to Nursing Unit. If a unit is returned after a 30-minute time limit, we will hold that unit for up to 4 hours for

original recipient only. We can reissue unit to original recipient providing that transfusion of unit can be completed within 4 hours of original issue time. We cannot issue this unit to another recipient. Before infusion of any blood component, identity of intended recipient and intended infusion product(s) must be verified. Patient information (name, medical record #) found on the: Unit tag attached to blood product and patient armband must match exactly. Patient Armband: This identification should also include unit numbers of the blood product(s), which are found on the unit-tag and on unit container. Two nurses, 2 doctors, or a combination thereof should perform identification, except for RhoGAM. In the absence of 2 doctors or 2 nurses, 1 doctor or 1 nurse should perform identification with another available staff member. The persons performing identification must sign unit-tag. This identification must be performed at the patient s bedside. Unit-tag must remain attached to the component until end of transfusions. If any discrepancy is detected, return blood product and all Blood Bank slips to Blood Bank immediately for resolution. Before transfusion, unit of blood should be thoroughly mixed by gentle inversion. Each unit of blood has printed instructions for administration on label. Patient s blood pressure, pulse, temperature, and blood unit number should be recorded in nursing notes, as well as on unit-tag just prior to transfusion. Recording of vital signs provides a necessary baseline for later observations. When blood is released for emergency transfusions under unusual circumstances, a special notation will be attached directly to blood unit (BLOOD WARNING TAG). This information should suggest to physicians and nurses that particular caution must be exercised during transfusion, and that infusion should be terminated at first sign of any untoward reaction. If the persons starting transfusion have any questions about significance of this information, they should contact the Blood Bank before transfusion of blood. Routine crossmatch procedures will be completed ASAP. The following are examples of situations when a special warning is used: A patient presents a problem in typing and/or screening, but problem has not been thoroughly investigated by Blood Bank personnel due to immediate need for blood. Least reactive or crossmatch compatible blood is issued. A patient has autoimmune hemolytic anemia so that compatible blood is not available. Rhgenotype specific blood is issued. Please remove warning tag prior to infusion. Warning tag is for transfusionist s information. During Transfusion: The first 50-mL of blood should be infused slowly at 50 drops/minute as a test for an acute untoward reaction. Patient s vital signs should be checked again at 15 minutes. Most serious transfusion reactions will be apparent by this time. If patient s condition remains satisfactory, flow rate may be increased to 60 to 80 drops/ minute. Patient should be monitored periodically for remainder of transfusion. Transfusion should be completed in no more than 4 hours, 2 hours or less is preferred. If physician has indicated a transfusion time in excess of 4 hours, Blood Bank personnel can split unit and issue a small portion of unit while keeping the rest under monitored refrigeration for later infusion. Recommended transfusion times for blood and components are as follows: Component Red cells (300-350 ml) Platelets, random: platelets, pheresis (330-400 ml) Fresh frozen plasma (150-250 ml) Cryoprecipitate (20 ml) (normal dose 6-12 units, 120-240 ml) Recommended Infusion Time 2 hours best, but not to exceed 4 hours 30 minutes for pool of 6 random platelets or a single pheresis platelet 20 min/unit 20 to 30 minutes for standard dose Any transfusion that stops or slows appreciably during administration should be investigated. This is especially critical when a blood warmer is being used. Prolonged transfusion time also increases the chance of bacterial contamination in the blood unit. Signs and symptoms of a transfusion reaction follow in this chapter. At the Termination of the Transfusion: Record vital signs on unit-tag. Transfusionist must record presence or absence of a reaction on unit-tag. Original copy of unit-tag is to be retained for patient s chart. Empty blood bag should be disposed of on floor, except in cases of suspected transfusion reaction, in which case

blood bag and IV tubing should be sent to Blood Bank. Completed department copy of unit tie-tag should be returned to Blood Bank for all transfusions. Experienced personnel should observe patient who has received a transfusion for several hours. In case of a reaction, a properly completed Transfusion Reaction Investigation Record form must be filed in the Blood Bank before laboratory investigation is started. Unit number(s) of component(s) associated with reaction should be entered on this form. Intravenous solution, such as isotonic saline, used to start blood transfusion should be continued only if specifically ordered after blood or blood product is completely administered. Transfusion Reactions This manual is not intended to be a complete examination of all aspects of transfusion problems. It is designed to be used as a helpful guide for doctors and nurses when transfusion complications do occur. Transfusion reactions are as individual as the patients they affect. Descriptions of reactions may hold true only in part for a particular patient or may be masked by the patient s own disease process or medications taken prior to infusion. This manual should be kept handy at all nursing stations for quick reference. Transfusion reactions may be defined as any unfavorable event occurring in a patient during or following transfusion of blood or blood products. Since compatibility testing is performed for detection of antibodies to red cell antigens, adverse effects of transfusion are most commonly caused by other elements of blood, ie, leukocytes, platelets, plasma proteins, and infectious agents that may be present in blood products. In addition, every transfusion carries risk of development of red cell antibodies and transmission of disease. Transfusion complications fall into 2 major groups: Immediate reactions, seen within 48 hours of administration Delayed reactions and transmission of disease Whenever a reaction is suspected: Recheck identity and identification numbers of patient and component. Stop (but do not disconnect) infusion. Restart saline flow to keep open. Call patient s physician. Notify Blood Bank. Patient s physician or a staff physician should examine patient to establish severity of reaction. In certain minor reactions, blood may be cautiously restarted after patient has been treated with antihistamine. If situation warrants, nursing staff must initiate a Transfusion Reaction Investigation Record form, signed by attending physician, for swift and accurate investigation of these complications. In addition, a fresh urine specimen should be collected from patient and sent to laboratory ASAP. The Laboratory will come draw blood on patient if additional testing is needed. Immediate Effects Hemolytic Reactions: These reactions are usually due to clerical errors, misidentification of patient and/or donor unit, or direct abuse of blood product. Antigen-antibody interactions may also cause true hemolytic reactions. Red cell destruction may be intravascular, where red cells are hemolyzed directly in blood stream. Extravascular hemolysis, where red cells are removed by the reticuloendothelial system after reacting with an antibody, can lead to hyperbilirubinemia, with little or no release of hemoglobin into plasma. Clinical signs signaling hemolytic transfusion reaction will vary according to type of red cell destruction involved. Intravascular hemolysis is accompanied by immediate clinical signs associated with substances released by action of certain blood proteins (histamine, hemoglobin). There may be: Feeling of heat along vein into which blood is being infused Flushing of face Pain in the chest, lumbar region, or severe headache Nausea and vomiting Fever and chills Shock Signs associated with extravascular hemolysis may not be so dramatic, including only chills and fever several hours after infusion has ended. In an anesthetized patient, the only signs of a reaction may be an unexplained increase in pulse or increased bleeding. Hemoglobinemia and hemoglobinuria may occur, and severely affected patients may have complete renal shut down. Acute hemorrhagic diathesis can often be the outcome of a hemolytic reaction; it may be the ONLY sign of such a reaction if patient is anesthetized. Hemolysis may also initiate disseminated intravascular coagulopathy with consumption of

coagulation factors and fibrinolysis. Hemolytic events due to non-immunologic causes are not uncommon. Non-immune hemolysis may be due to overheating or freezing of infused blood, exposure to extreme osmotic stress, or to trauma and rarely causes life-threatening complications of immune type hemolytic reaction. Still, contaminated plastic sets or IV fluids can occur, and this possibility should be considered when other investigations are unproductive. Transfusion Related Acute Lung Injury (TRALI): TRALI is defined as any reaction including respiratory symptoms developing within 6 hours of a transfusion. This syndrome usually occurs following administration of plasma, but all components have been implicated. TRALI is now the most frequent cause of transfusion-related fatality. The most common presentation is respiratory distress (dyspnea, cyanosis), hypoxemia, and noncardiogenic pulmonary edema. In addition, hypotension resistant to fluid challenge and fever constitute the original pentad describing this syndrome. Respiratory and hemodynamic support are the keys to good patient management in TRALI. Respiratory regimen should be as intensive as that dictated by clinical picture. In almost all cases, oxygen supplementation is necessary. If hypoxemia is severe, intubation and mechanical ventilation will be necessary. Pressor agents are often essential in cases of sustained hypotension. Corticosteroids and diuretics have not been shown to be of clinical value. Anaphylactic and Allergic Reactions: When blood is transfused, patient receives more than 40 different plasma proteins, and sensitivity to one or a number of these can occur. The cause of these reactions is far from clear. Symptoms of allergic reaction may include: Urticaria (hives) Rash Chills and fever Allergic reactions are usually treated with antihistamines Circulatory Overload: Sudden increase in circulatory blood volume is not well tolerated by certain patients, particularly patients with cardiac or pulmonary disease, very anemic patients, or infants. Blood transfusion in these patients may cause dyspnea, coughing, pulmonary edema, or cyanosis. If these develop, STOP THE TRANSFUSION; and start treatment for circulatory overload. Units should be given at the rate of 100 to 150 ml/hour. Bacterial Reactions: Bacteria may cause transfusion reactions in 2 ways: By production of febrile reactions due to pyrogens and toxins which are breakdown products of bacteria. By causing serious, often fatal reactions, when donor blood is contaminated with large numbers of living organisms. Septic reactions are often caused by cryophilic organisms, that is to say, those capable of growing at low temperatures, eg, pseudomonads, coliforms, and achromobacters. They are usually endotoxin-producing gram-negative bacilli that can metabolize citrate as a sole source of carbon. When bacterial contamination is suspected, microscopic examination and culture of donor blood is indicated. A Gram stain and culture are automatically performed as part of a transfusion reaction investigation whenever the posttransfusion temperature rises 2.5 F. When infected blood is transfused, symptoms appear quickly (10-30 minutes) ie, chills, headache, vomiting, muscle pains, diarrhea, and high fever. Prompt, energetic treatment is required. Transmission of Disease: Transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) from donor blood to recipient constitutes, at present time, the most common and serious problem of transfusion practice. Components such as platelets, plasma, cryoprecipitate, and fibrinogen are also responsible for HIV/HBV/HBC risk. Serum albumin, plasma protein fraction, and globulin are considered safe products, since their preparation inactivates most viruses. It is imperative that either the Blood Bank or the pathologists be contacted when a recently transfused patient shows signs of hepatitis, or any liver involvement, so that investigation can start immediately. All homologous components transfused at the MidMichigan Laboratories are tested and found to be negative for hepatitis B surface antigen (HBsAg), hepatitis B core antibodies, total (Anti-HBc), anti-hiv1/2, human T-Cell lymphotropic virus types I and II antibodies (Anti-HTLV), and anti-hiv1 antigen. Nucleic acid testing for HCV, HIV, and West Nile virus was recently instituted and NAT testing for HBV will start in the very near future. In addition, homologous units are also tested for syphilis. An algorithm for Chagas disease testing will begin in 2007. Autologous units are tested only for anti-hiv1/2.

What to Do if a Transfusion Reaction Occurs Symptoms: Temperature elevation of 1.8 F. Temperature should be taken before infusion, at 15 minutes and then periodically thereafter until infusion is complete. Hives, rash, itching, etc. may be signs of allergic reaction Heat along infused vein, headache, and pain in chest or lumbar region Nausea, vomiting, diarrhea Chills and/or uncontrollable shaking Shortness of breath, cyanosis, hypoxia Continuous bleeding in an anesthetized patient or unexplained increase in pulse rate With any of the above symptoms: Stop (do not necessarily disconnect) infusion. Recheck patient and donor unit identification. Record all symptoms. Call a physician to examine patient. Notify Blood Bank at Clare (989-802-8856), Gladwin (989-246-6263), Gratiot (989-463-1101 ext 4415) or Midland (989-839-3480), Complete Transfusion Reaction Investigation Record form, located in FormFast, and send it to the laboratory. Collect a urine specimen from patient, and send it to laboratory ASAP. If a bacterial reaction is suspected, or if transfusion is complete, send empty bag to Blood Bank. Laboratory will draw blood specimens from patient and let you know results ASAP.