Transfusion at RCH BLOOD TRANSFUSION Anthea Greenway Dept of Clinical Haematology >10000 fresh blood products per year Supports craniofacial and cardiac surgery Support bone marrow, liver transplant and cancer chemotherapy Supports PICU (ECMO/VAD) and NICU Currently approximately 60 transfusion reactions per year reported Incidents seen by the transfusion service STIR Blood is serious business What are the expectations for junior medical staff in the management of transfusions Assessment Consent Prescription Review Transfusion reaction management Indications: RBC S Hb <70g/L; although lower thresholds may be acceptable in patients without symptoms and where specific therapy (eg iron) is available. Transfusion may be indicated at higher thresholds for specific situations: Hb <70-100g/L during surgery associated with major blood loss or if evidence of impaired oxygen transport Hb <80g/L; patients on a chronic transfusion regimen or during marrow suppressive therapy (for symptom control and appropriate growth) Hb <100g/L; only for very select populations (eg. neonates) Indications: Platelets Bone marrow failure: Plt <10x109/L if no other risk factors for bleeding (see below) Plt <20x109/L if risk factors present (fever, antibiotics, haemostatic failure, risk of intracranial haemorrhage) Surgery/invasive procedure : Plt <50x109/L. higher with high risk of bleeding eg. neurosurgery 1
Indications: Platelets Platelet function Defects-Transfuse if there is bleeding or high risk of bleeding, regardless of actual platelet count Bleeding/Massive transfusion: Maintain Plt >50x109/L if thrombocytopaenia likely contributing to bleeding Maintain Plt >100x109/L in the presence of diffuse microvascular bleeding (DIC) or CNS trauma Indication: FFP Warfarin effect, in the presence of lifethreatening bleeding in addition to the use of vitamin K and vitamin-k dependent clotting factor concentrates for bleeding with abnormal coagulation Liver disease, if bleeding with abnormal coagulation. Acute DIC when there is bleeding and abnormal coagulation Following massive transfusion or cardiac bypass for bleeding in the presence of abnormal coagulation Indication: Cryoprecipitate Fibrinogen deficiency, in the setting of clinical bleeding, an invasive procedure, trauma or DIC. Consent Resources for Consent Consent and documentation guideline Component information (booklet) Kids information packs (intranet) What needs to be covered Explanation of why transfusion is necessary Benefits vs risks Adverse outcomes Alternatives Documentation in the medical record or on procedural consent form Adverse Effects of Transfusion: Risks of Transfusion: Immunological: Acute or delayed haemolytic transfusion reaction Allergic reaction Anaphyaxis Febrile, non haemolytic TRALI Alloimmunisation Post transfusion Purpura TAGVHD Non-immunological: Massive Transfusion Metabolic Non-immune haemolysis Sepsis TACO Iron overload Transfusion transmitted infection The risk per unit for specific viral infections is as follows: HIV: approximately 1 in 5.4 million h titi C i t l 1 i 2 7 illi hepatitis C: approximately 1 in 2.7 million hepatitis B: approximately 1 in 739,000 HTLV 1/2: approximately 1 in 17.5 million 2
Volumes How to prescribe blood for children RESOURCES Intranet CPG Blood Transfusion, indications, volume calculations and rates About Blood Products Information about platelet ordering Special blood product ordering Emergency blood release Special Requirements: Leukocyte depleted blood products should be given to: Immuno-compromised patients (oncology, transplant recipients, ICU patients, and other congenital and acquired immune deficiencies) Patients requiring chronic transfusions Infants under 12 months Intrauterine or exchange transfusions Irradiated blood products should be given to: All immuno-compromised patients, including all oncology patients, cardiac neonates and all patients in ICU, to prevent graft-versus host disease. CMV negative products: Leucocyte depleted blood products, are considered an acceptable alternative to CMV seronegative products at RCH Transporting of Blood products Timer bags Blood in motion bags 30 minute rule 4 hr rule ON THE BACK OF THIS FORM The components of the blood check bag, bag tag, transfusion record, prescription and patient identification label Is this form Observations The patient should be observed closely with in the first 15 minutes Observations must include: temp, BP, HR and RR Observations should be performed Before commencement of transfusion at 15 minutes and then hourly until completion at the conclusion If there is any unusual findings then these should be reported and the patient reviewed 3
Suspect a transfusion reaction? RECOGNISE: Fever (>38.5 C or increase 1.5 C above baseline) Chills Hypotension/ hypertension Urticaria Pain (alone infusion line, chest and back) Headache Nausea/vomiting Acute respiratory distress Bleeding, oozing Dark urine REACT: STOP TRANSFUSION (but leave line in place) Provide emergency patient care Arrange medical review Flush IV line or attach side arm Re-perform checks 1-4 of pretransfusion check REPORT: Telephone hospital blood bank 5829 Complete the transfusion reaction report form Document reaction and management in the patient record If you have any concerns page the Haematologist on-call or page Transfusion Nurse 6562 If transfusion is discontinued Disconnect pack from patient Complete Transfusion Reaction Report Form Obtain requested blood or urine samples Send pack, Transfusion Reaction Report Form and samples to hospital blood bank In conjunction with Haematologist decision made re: further transfusion requirements T R A N S F U S I O N Fever/chills Hives/itching Dyspnea Hypotension FNHTR Bacterial Contamination Acute HTR Mild Allergic Circulatory overload Anaphylaxis TRALI Anaphylaxis Acute HTR Bacterial contamination TRALI Hospital resources Transfusion committee RCH Blood Bank Transfusion nurse Pager 6562 On call Haematologist Blood Transfusion intranet site Resources Other Resources ARCBS website Component booklet 4
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