Blood Transfusion Dr William Dooley
Plan Cases Blood groups / Indications Procedure Monitoring / Reactions
Cases For following cases: - Would you give them a blood transfusion? - How many units you would prescribe? - What other investigations/management would you consider? 1. 23 yo asymptomatic, healthy woman with menorrhagia Hb 84 g/l, MCV 73fl 2. 86 yo asymptomatic man with occasional angina Hb 96 g/l, MCV 104fl 3. 73 yo man presenting with acute upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/dl, MCV 101fl
Cases 1. 23 yo asymptomatic, healthy woman with menorrhagia Hb 84 g/l, MCV 73fl Microcytic anaemia Iron deficiency Mx: Oral iron replacement (e.g. Ferrous Sulphate 200mg TDS) No tranfusion Ix: If severe 2. 86 yo asymptomatic man with occasional angina Hb 96 g/l, MCV 104fl Macrocytic anaemia Mx: Treat cause Ix:?cause: alcohol, meds, hypothyroidism, haemolysis
Cases 3. 73 yo man presenting with acute/severe upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/l, MCV 101fl Acute anaemia Mx: Cross Match and transfuse 4-6 units Urgent OGD Ix: FBC / Coagulation
Indications for Blood Transfusion Acute Anaemia (rarely chronic anaemia) Symptomatic anaemia and blood loss. Peri-operative: replacing losses Haemolysis (treat underlying cause) Case-case basis Co-morbidities Symptoms Cause Patient choice Threshold of Hb? Transfusion should be considered if Hb below 80 g/l If the Hb is below 70 g/l transfusion is usually indicated
Blood products Packed Red Cells Commonly used to correct anaemia and acute blood loss 1 unit raise haemoglobin by ~10-15g/l in 70kg patient Platelets For severe thrombocytopenia; consider if patient still actively bleeding 1 unit raise platelets by 20x10 9 Same bedside checks and ABO/RhD checks as with red cells Fresh Frozen Plasma (FFP) Contains all the coagulation factors. Indicated in clotting defects e.g. Disseminated Intracellular Coagulopathy Whole blood Rarely used components more valuable
Blood Groups UNIVERSAL RECIPIENT UNIVERSAL DONOR UK Frequency 42% 8% 3% 47%
OSCE Scenario 33 yo woman with menorrhagia, complaining of lethargy, palpitations and dizziness. Obs: HR 110 BP 125/89 RR 16 FBC: Hb 54 g/l, MCV 73fl 1. Discuss options for management with the patient and gain valid informed consent patient for blood transfusion. 2. Prescribe the blood products 3. What pre-transfusion checks are required 4. Set up the transfusion 5. What monitoring is required during the transfusion
Transfusion discussion 1. The following information should be discussed: Type of blood / blood component Indication for transfusion Benefits of the transfusion Risks of transfusion Possible alternatives to transfusion How the transfusion is administered and the importance of correct patient identification Inform patient that following a blood transfusion they can no longer be a blood donor. 2. Provide written information. 3. Check if patient needs time to consider or requires further information. 4. Document the discussion in the patient s clinical records.
Prescribing Blood Different at different Trusts but principles the same Usually on separate blood transfusion chart, prescribe: Packed Red Cells Timing: Needs to be complete in 4 hours (so logistically usually over 1-3 hours) Same prescribing principles as with normal meds: sign/print name, date, time
Blood sample Positive ID check- surname/forename/dob Confirm with ID wrist band and request form Group and Save vs Cross Match Write details on blood bottle after blood added Pt ID (name/dob/hospital number), patient location, date/time of sample, signature of person taking blood
Pre Transfusion Checks what to check
Pre Transfusion Checks how to check Ask patient full name and DOB (positive ID check) at bedside TWO STAFF; Check this against their wristband (patient must be wearing) Check details (plus hosp no.) against compatibility label / request form Confirm prescription chart completed Check blood unit label expiry date / number and blood group Check the blood bag ensure free from clots / leaks Record- blood pack number, date/time and signature of both staff Send request label back to lab to monitor completion
Putting up the blood Aseptic technique wash hands, gloves, apron Check expiry of (double lumen) giving set Connect the giving set to the blood bag Squeeze blood into both chambers Prime the giving set with blood Attach to cannula Set drip rate Document
During procedure checks When should observations be checked? Initial/baseline observations 15 minutes after starting Hourly thereafter At end of transfusion What should you be checking for? Temperature HR/BP RR/Sats What symptoms should you be advising the patient to report? Chest/Abdo pain SOB Restlessness/anxiety Rash Blood in urine
When to stop the transfusion Temperature - Increase by 1 degree Blood Pressure - Significant change (+/- 10mmHg) Heart Rate - Significant rise
New OSCE Scenario 74 year-old female with GI bleed Transfused 1 unit Platelets & 4 units RBCs During transfusion Difficulty breathing Hypoxia Increased respiratory rate
Complications which one? Acute haemolytic reaction Allergic rxn Graft vs host disease TRALI Infections Post-transfusion purpura Fluid overload Non-haemolytic febrile transfusion rxn Anaphylaxis Bacterial contamination
Transfusion Reactions Early vs Late General management principles: Stop transfusion Maintain line with IV Fluid Send blood product to lab New FBC/U+E/Clotting samples Call for help Document and report symptoms Think specifics for management
Early vs. Delayed complications Early (<24hrs) Acute haemolytic reaction Anaphylaxis Bacterial contamination TRALI / TACO Non-haemolytic febrile transfusion rxn Allergic rxn Late (>24hrs) Infections Iron overload Graft vs host disease Post-transfusion purpura
Early: Acute haemolytic reaction e.g. ABO incompatibility commonly clerical errors Signs/symptoms: agitation, rapid onset fever, hypotension, flusing, abdominal/chest pain, DIC +/- death Management: STOP TRANSFUSION Check blood and patient details Send unit of blood back to lab Urgent FBC, Clotting, U+E, cultures and urine IV Fluids LARGELY PREVENTABLE COMMONEST CAUSE = HUMAN ERROR
Acute Lung Complications: TRALI vs. TACO Transfusion Related Acute Lung Injury Dysponea, cough Transfusion Associated Circulatory Overload Signs/symptoms Dysponea, hypoxia, tachycardia, creps +/- echo/bnp Management STOP Transfusion STOP Transfusion High flow oxygen Give high-flow oxygen Diuretic (furosemide) Treat as ARDS
Acute: Other reactions Non-haemolytic febrile transfusion reaction Shivering and fever (1-1.5hrs post starting) Unpleasant but not life threatening Rx- SLOW / STOP Transfusion. Give anti-pyretic (paracetamol) Bacterial Contamination Fever, hypotension and rigors Rx- STOP transfusion, Urgent septic screen, Broad spec ABx Anaphylaxis Bronchospasm, cyanosis, hypotension, soft tissue swelling Rx Slow/stop transfusion. Maintain airway + Oxygen. Call Anaesthetist Allergic reaction Urticaria and itch Rx with Chlorphenamine
Chronic: Infections Risk of HIV per unit transfused = 1 in 6 million Risk of Hep B per unit transfused = 1 in 1.3 million Risk of Hep C per unit transfused = 1 in 28 million All tested for Hep B / Hep C / HIV 1&2 / Human T-cell lymphotropic virus / syphilis +/- CMV and malaria Risk = asymptomatic window period
Chronic: Other Post Transfusion Purpura 5-7 days post transfusion Platelets fall can be lethal Graft-versus-host disease Rare. Fatal. Donor lympocytes mount an immune response against the immunocompromised host Prevented by irradiation of donor blood
the life of all flesh is the blood thereof: whoever eat it shall be cut off (Lev. 17:10 16) abstain from the meats offered to idols and from blood (Acts 15:28 29) (1 3).
Summary Is blood transfusion necessary? If so, ensure: Right blood Right patient Right time Right place Gained valid and informed consent Documented ANY QUESTIONS??? Monitor