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Paediatric Safe Transfusion Practice Workbook
Diana Agacy Cowell, RGN, Adv Dip-Child Health, Adv Dip Psychiatry & Psychology and BSc
Specialist Practitioner of Transfusion Pathology 2009
2
Administration of Blood Components and Products
Safe Transfusion Practice Table of contents page Learning outcomes 3
Overview 4
Safe Transfusion Practice 6
Anatomy and physiology of blood 7
Red blood cells: 8
Normal Paediatric Haematology values: 8
Platelets and Fresh Frozen Plasma (FFP): 9
Normal Coagulation Screen values: 9
ABO Blood Group 10
Rh D Blood Group 12
Haemolytic disease of the new born: 12
Sample Taking 14
Pre-collection checklist 15
Collection and Transport of Blood Components 15
Receipt of blood components in the clinical area 16
Administration of Blood components 6 17
‘Final bedside check’ 17
Transfusion rate: 17
Care of patient being transfused 9 17
Observations required for a Blood Transfusion 17
End of transfusion: Disposal of empty packs 18
PROCEDURES6 19
Preparing for a transfusion 19
Checking the blood component 22
Transfusion of platelets 23
Transfusion of FFP 24
Transfusion of red cells 25
PATIENT MONITORING 25
If there has been a reaction see page 27 26
Procedure for reporting adverse reactions 27
Types of reactions 27
Procedure following reactions 30
Appendix 1: Equipment Required for Transfusion 5 31
Cannulae / Venous Access Devices 31
Blood Giving Sets / Blood Administration Sets 31
Infusion Pumps 32
Pressure devices 32
Blood Warmers 32
Appendix 2: Adverse Reactions to a Blood Transfusion 5 33
Recognition of an acute adverse reactions 33
Types of Acute Reactions 33
Appendix 3: 36
MCQ 38
Glossary 40
References 42
3
Learning outcomes Upon completion of this chapter, the reader should be able to accomplish the following:
1. Define the purpose of a red cell transfusion, platelet transfusion and a Fresh Frozen Plasma (FFP) transfusion.
2. Demonstrate a basic knowledge of the ABO and the Rh D blood groups.
3. Identify the various stages of the Blood Transfusion Process. 4. Identify the difference between a Group & Screen sample and a Cross-
Match sample, and the correct process of labelling these samples. 5. Identify the correct procedure of collection and transportation of blood
components. 6. Identify the equipment required for a blood transfusion. 7. Explain the safe process for the administration of different blood
components. 8. Discuss the care of a child receiving a blood transfusion and rationalise
your answers. 9. Discuss potential adverse reactions to a blood transfusion. 10. Discuss the risks of blood transfusion and identify the biggest risk of
transfusion. Explain how this risk can be completely eliminated.
4
Overview
In an acute hospital setting the transfusion of blood components and blood
products is an integral part of everyday life however it is a finite commodity as
we rely on voluntary donors for its supply. The National Haemovigilance
Office states that blood components and products are life saving and when
used appropriately they will improve the quality of life in a large range of
clinical conditions. However, it is also widely recognised, that as in any other
clinical intervention, there are a number of risks associated with this therapy,
transfusion transmitted infections (TTI) and human error. The quality of blood
has been given precedence over that of human error due to the impact of
hepatitis, human immunodeficiency virus (HIV) and more recently variant
Creutzfeldt-Jakob (vCJD) disease. However in the last decade the Serious
Hazards of Transfusion (SHOT) scheme1 has attributed most major incidents
to human error.
Safe Transfusion Practice relies on collaborative teamwork, as blood
transfusion is a complex, high risk and multi-step procedure. The Transfusion
Process crosses several professional boundaries and involves many
individuals. There are at least 23 stages between taking a pre-transfusion
compatibility blood sample, the recipient receiving their transfusion and the
completion of the transfusion.2 Six different professional groups intervene at
different stages of the process and with each stage there is the potential of
error.
In 2005 when the European directive for blood was transcribed into British
criminal law as the Blood Safety and Quality Regulations (2005)3 it became a
legal requirement that every unit issued for transfusion had to be fully
traceable from donor to recipient, vein to vein traceability. The health
professional responsible for communicating the final fate of every unit in the
clinical area is the responsibility of the nurse as they are invariably the ones
that administer the transfusions on the wards. To make this process easier
most hospitals, if they have not already, are in the process of implementing an
electronic tracking system to meet the above requirements. The laborious
5
paper systems, which might be still in use in some hospitals, are unreliable
and few have achieved 100% traceability as they rely heavily on the health
professional remembering to sign, date and return the traceability slip.
Despite this change from paper to electronic systems the transfusion process
will remain the same and the same safety steps will need to be followed.
With the transcription of the EU Directive on Blood Safety and Quality
Regulations in to British criminal law also came a new Haemo-vigilance
scheme which is monitored by the MHRA (Medicines and Healthcare
Products Regulatory Agency) known as S.A.B.R.E. (Serious Adverse Blood
Reactions & Events). This new scheme works alongside SHOT.
6
Safe Transfusion Practice Paediatric patients should not be exposed unnecessarily to blood components
and products as there is always the potential risk of transfusion transmitted
infections, those that we are aware of and those yet to be discovered.
Therefore it is important to check the most recent haemoglobin result and
assess the patient for signs of anaemia. If the patient is not actively bleeding,
infection free and haemodynamically stable, query the transfusion, protect
your patient. Remember the use of blood requires a conservative approach as
the safest transfusion is the one not given.
It is important to follow procedure even though at times it can be quite
prescriptive but the evidence demonstrates that when we disregard procedure
errors occur. In 2005 SHOT4 published Serious Hazards of Transfusion report
for children as they were worried about the increasing incidents in paediatrics.
The 2007 SHOT1 reported a paediatric death directly related to a human error
which resulted in an ‘over transfusion’. The error was attributed to the
misunderstanding of a verbal prescription of the rate and volume of a
transfusion of platelets.
Children are a particularly vulnerable age group apart from having many
special requirements there are other concerns such as: 4
• Neonates are particularly susceptible to infective and toxic effects of
transfusion owing to their immature immune and metabolic systems
while they are still going under rapid neurodevelopment.
• Consideration must be given to long-term side effects of transfusion as
the majority have decades of life ahead of them.
• The acute side effects of transfusion may be greater in children than in
adults as a single unit may represent a much greater proportion of their
blood volume.
• In general paediatric wards transfusions are rare therefore there is less
awareness of transfusion related hazards.
7
Anatomy and physiology of blood
Blood is a highly specialised circulating tissue consisting of several different types of cells suspended in a straw coloured fluid called plasma5.
Cellular Constituents Function
Red cells or erythrocytes Carry respiratory gases and give it its red colour because they contain haemoglobin, an iron containing protein that binds to oxygen in the lungs and transports it to the tissues in the body.
White cells or leucocytes
Fight infection
Platelets or thrombocytes
Cell which play an important part in the clotting of blood
The main components transfused are red blood cells (Rbc), platelets, plasma (non-cellular) and cryoprecipitate (non-cellular). In this chapter we will focus on the first three as they are the most commonly used components. All components and products are derived from whole blood. Whole blood
Plasma Red cells Platelets
Red blood cells 45% WBC and platelets <1% Plasma 55%
8
The National Blood Service (NBS), part of the National Health Service Blood and Transplant (NHSBT) take whole blood from voluntary donors. These voluntary donations are then processed, to provide us with the components we see in hospital 5.
Blood components Red blood cells: Red cells are prescribed to treat anaemia and haemorrhage. Causes of anaemia:
• Iron deficiency
• Vitamin B 12 deficiency
• Folate deficiency
• Bone marrow failure
• Secondary to chemotherapy.
• Slow bleeding, especially from gastro-intestinal tract. The diagnostic test used to detect anaemia is the ‘Full Blood Count’ (FBC). One of the indices measured by this diagnostic test is the level of haemoglobin (Hb) and it is this Hb level that is used to quantitate the degree of anaemia. The FBC is a valuable test for the diagnosis of anaemia as it provides other valuable data which Haematologist use to differentiate between types of anaemia. Normal Paediatric Haematology values: Table 1
Haemaglobin (Hb) g/dl Infant (2-6 month) 10-15 Child (1-12 years) 11-16 Adolescent: male 13-16 Adolescent: Female 12-16 Critical values <5 or > 20
Platelet/thrombocyte count x109 /litre Infant/child/youth 150-450 Critical values <30 or>7100
Fresh Frozen Plasma (plasma)
Packed red cells (red blood cells)
Platelets
9
Red cells are stored in refrigerators in the Blood Transfusion Laboratory (BTL) or in designated refrigerators, often referred to as satellite blood banks or satellite refrigerators. The temperature of these refrigerators are strictly monitored in order to preserve the quality of red cells. It is important to maintain red cells at 2 o to 6o C. Therefore under no circumstances should red cells ever be stored, even for a short period, in the ward refrigerator Platelets and Fresh Frozen Plasma (FFP): Platelets and FFP are prescribed to treat a coagulopathy. That is to stop excessive internally or externally bleeding or in some circumstances to prevent bleeding. The FBC provides us with the number of circulating platelets (Table 1). While the diagnostic test ‘Coagulation screen’ (CS) will indicate if FFP is required depending on the International Normalised Ratio (INR). Normal Coagulation Screen values: Table 2
International Normalised Ratio (INR)
Infant (2-6 month) 0.9 – 1.2 Child (1-12 years) 0.9 – 1.2 Adolescent: male 0.9 – 1.2
Adolescent: Female 0.9 – 1.2 Critical values > 5
FFP is stored frozen, hence the name, in the BTL and is defrosted before it is sent to the clinical area. Platelets are stored in an incubator at approximately 22o C on a ‘rocker’. The gentle motion of the rocker prevents the platelets from aggregating. Platelets should never be stored in a refrigerator. Platelets and FFP are ordered on a named patient basis. Patients borne after January 19967
In order to minimise the risk of transmitting new variant CJD these patients should receive pathogen reduced FFP sourced from outside the UK. This would either be methylene blue or solvent detergent treated FFP (Octaplas).
10
Blood groups
There are many blood group systems along with their sub-groups but at this stage we will limit our attention to the two most clinically significant blood groups, the ABO and the Rh D blood systems. All blood groups are inherited and there are two ways of reporting the ABO blood group, the genotype or the phenotype. The latter is the most common of the two. ABO Blood Group Genotype A O B O Phenotype (Vignette 1)
Table 3
The table 3 shows which blood group each recipient is compatible or suitable with depending on the component they need.
Dad Mum
Daniel O
Lisa O
Mary AB
O or A or BO, A, B, ABOO
A or B or OABAB, A, B, OAB
B or A or OB or ABB or OB
A or B or OA or ABA or OA
Donor platelets
Compatible with:
Donor FFP
Compatible with:
Donor red cells
Compatible with:
Recipient/Patient
ABO
Blood Group
11
This choice is dictated by a substance that is present or absent on the red cells of the recipient.
People who are blood group A have an ‘A’ substance (antigen) on their red cell membrane. This ‘A’ substance stimulates the production of Anti B Antibodies that will circulate in plasma. The function of these antibodies is to defend the body from B antigens which are present on the surface of B red cells and AB red cells
People who are blood group B have a ‘B’ substance (antigen) on their red cell membrane. This ‘B’ substance stimulates the production of Anti A Antibodies that will circulate in plasma. The function of these antibodies is to defend the body from A antigens which are present on the surface of A red cells and AB red cells
People who are blood group AB have both the ‘A’ and ‘B’ substances (antigens) on their red cells. The presence of both the substances prevents the stimulation and therefore the production of Antibodies in plasma.
People who are blood group O do not have ‘A’ or ‘B’ substance (antigens). Hence they produce A,B Antibodies in plasma.
The rationale for producing the specific antibodies is to defend the body from what is foreign to it. Example:
• Elizabeth is blood group A and needs a red cell transfusion.
• John is blood group B and wants to donate blood to give to Elizabeth.
• However if John’s red cells are transfused to Elizabeth the anti B antibodies in Elizabeth’s plasma will destroy John’s donated B red cells causing haemolysis.
• This will make Elizabeth very ill and it can be fatal.
• Elizabeth can only receive type A or O red cells
• The absence of AB antigens on O red cells make them safe to transfuse to A, B or AB recipients.
A
B
AB
O
12
Rh D Blood Group In the past, though you will still hear the term used, this blood group was referred to as the Rhesus blood group. However, the term Rhesus refers to the species of monkey in which a similar antibody to that of the human version was discovered. Using the previous example both blood groups would be reported as: Elizabeth is ‘A negative’ or ‘A Rh D negative’ John is ‘B positive’ or ‘B Rh D positive’ Negative means the absence of the Rh D factor on the surface of the red cell membrane. Those that have this factor on their red cells are said to be Rh D positive. However, unlike the ABO antigens, the antibodies against the Rh factor are developed either through placental sensitisation or transfusion. That is a person who has never been exposed to the Rh D antigen will not posses the Rh D antibody e.g. Haemolytic disease of the new born:
Rh status of the baby is unknown till it is born If the foetus is Rh D negative like the mother there is no problem but if the foetus is Rh D positive there could be a problem. Usually if it is the first pregnancy the child is born without any problems however the risk increases with future pregnancies. The problem occurs when the baby’s blood (RH D positive) crosses the placenta into the mother’s circulation. When this occurs the mother can become sensitised and her immune system will produce Rh D antibodies. These Rh D antibodies will attack an Rh D positive foetus causing haemolytic disease of the foetus and of the newborn.
Biological father Rh D positive
Mother Rh D neg
Foetus Rh D Pos or neg ???
13
1.
2.
3. =
= +
Y = antibodies * = red cell breakdown (Vignette 3)
Some cases may warrant an intrauterine transfusion. If the baby is born with a high billirubin count caused by haemolysis the baby will require an exchange transfusion. In order to avoid this Rh D negative pregnant women are offered preventive treatment with Anti D immunoglobulin however as it is a blood product some women refuse this treatment. Therefore it is important to always transfuse the right Rh D blood group. If a child or adolescent is Rh D negative they must always receive Rh D negative red cells and platelets. There can be exceptions to this rule during a major incident or severe donor blood shortage however this is beyond the scope of this chapter. The Rh D status does not affect the transfusion of FFP or cryoprecipitate.
Mum Rh D neg
Dad Rh D positive
Foetus Rh D
Pos or neg ???
Mum Rh D neg
Foetus Rh D Pos
Mum Rh D neg
Foetus Rh D Pos Y
Y Y
Y
* *
* *
*
Haemolysis
14
The Transfusion Process Sample Taking The transfusion process begins the moment a pre-transfusion sample is taken. For this purpose a request form indicating the nature of the test required must completed:
Pre - op, t o ns il le ct o my
D r. H G reen
2457
G ro u p & Scre e n
25/ 07/ 07 8. 45 DAC
JH N H AEM
07 89 12 3
S hep h ard
Jo hn
12 /0 3/1 96 0
S pr ing fo rd clo se
S W1 6P T
A group and screen/save is required for the transfusion of all components. For a cross-match the time, date and number of units required must be specified on the request form. This test is requested when a patient requires a red cell transfusion. Before taking a blood sample the person taking the sample must first obtain the patient’s or carer’s consent to take the sample and inform them of the purpose of the test. Use an open-ended question to identify the patient?
• Are you Tommy Smith? X
• Is this Tommy Smith? X
• Can you tell me your full name and date of birth? √√√√
• Can you tell me this boy’s full name and date of birth? √√√√
15
All blood samples for the BTL must have the following information: Patient’s:
• Forename
• Surname
• Date of birth (DoB)
• Hospital number or NHS number
• Gender The person taking the sample must sign, date and time the sample tube as well. The sample label must be completed by the person taking the sample before leaving the patient’s side or in outpatient clinics before the patient leaves the room. The labelling of blood transfusion samples in the event of a major incident or for unknown/unconscious patients vary at different hospitals. The reader is advised to find out what the local policy is for these situations. Once all of the above has been completed send the sample to the Blood Transfusion Laboratory (BTL). Pre-collection checklist
1. Patient is ready for the transfusion
2. Prescription & concomitant drugs are prescribed 3. IDENTIFICATION WRISTBAND in situ 4. Cannula in and Patent 5. Do your baseline observation 6. Equipment required for the transfusion (Appendix 1):
• Transfusion giving set
• Pump (see hospital policy)
• Protective equipment, usually just gloves and apron, as per hospital policy.
• 0.9% saline flush for intravenous access. Collection and Transport of Blood Components All blood components must be transferred from the site of collection e.g. BTL, satellite blood bank etc to the clinical area in a box or non-transparent bag. Blood components must be transferred directly from the collection point to the clinical area and the person who receives the unit on the ward should take it directly to the patient’s side in order to begin the transfusion immediately. Blood components should only be collected or requested for delivery when the patient is ready for the transfusion in order to avoid wastage. To collect any blood component the person doing the collection must take four points of patient identification (PID):
a) Forename b) Surname
16
c) DoB d) Hospital number/NHS number
Receipt of blood components in the clinical area Best practice is for the nurse who is going to administer the blood transfusion to go and collect the blood component. However, sometimes the collection is delegated to a porter, health care assistant or another nurse. The nurse requesting the collection must provide the person delegated to collect the component with the four points of patient identification. If it is a porter who is delivering the blood it is best practice for the nurse who requested the collection to sign the receipt of delivery. The receipt slip should include PID and the time of collection and delivery to the clinical area. It is important to patient safety and therefore the responsibility of the nurse to check that the blood component being delivered is the right one for the right patient. The blood component must never be left unattended. On delivery to the clinical area it should be checked and the transfusion should begin immediately. In some hospitals a single registered nurse may check and administer the component. While in other hospitals two registered nurses are required for the checking process but each must check the details individually and then sign the relevant paperwork.
17
Administration of Blood components 6
‘Final bedside check’
Step 1:
Check 14 digit donation number on the NBS unit label to the Unit Identification Label, if they match
Step 2: Check patient information on Unit to Identification Label
to patient’s ID wristband, if the information matches
Step 3: Prime the line with the blood component at the patient’s bedside/side and
commence the transfusion.
Transfusion rate: Red cells: For non-emergency transfusions the transfusion of red cells must
finish within 4 hours from the time the unit was taken out of the fridge. Most
red cell transfusions can be prescribed over 2 – 3 hours.
Platelets: Over 30 minutes
FFP: Over 30 minutes
Care of patient being transfused 9
Observations required for a Blood Transfusion
One Unit Two Units and more
Baseline Observations Baseline observations (taken at the end of transfusion of previous unit)
At 15 minutes following start At 15 minutes following start of each unit
At end of transfusion (this will form the baseline observations for 2
nd unit etc.)
At the end of each unit.
18
• Further observations will depend on the clinical condition of the patient or if the patient becomes unwell or shows signs of an adverse reaction to the transfusion.
• Unconscious patients can be difficult to assess for signs of adverse reaction to the transfusion and must be closely monitored during the first 15 minutes of each unit for any visual or vital sign changes.
• It is good practice to remain with the patient for the first 15 minutes of every unit transfused as this is when the majority of reactions occur. This is why some text books recommend that the rate of transfusion during the first 15 minutes should be slower than the prescribed rate. Once the 15 minute vital signs have been checked and no change has been observed from the baseline than the rate can be increased to the prescribed rate.
• It is important to physically observe the patient at regular intervals during the blood transfusion and to warn the patient or parents/carers to inform a member of staff immediately should the patient become agitated or develops a rash etc. (Appendix 2)
End of transfusion: Disposal of empty packs
• Empty packs should be kept on the ward until the current transfusion episode (one or more units in one session) is complete. If the patient’s observations have remained stable and no there have been no signs of an adverse reaction the empty packs maybe disposed of in ward clinical waste or returned to the BTL as per hospital policy.
19
PROCEDURES6 Preparing for a transfusion
No. Action Rationale
1
Consent
a) Formally identify the patient. Explain the procedure to the patient/parents/carers.
b) Assess for any history of reactions.
c) Obtain verbal consent from the patient/parent/carer for the transfusion to take place.
d) Document in Transfusion Record (TR) or in patient’s medical notes
e) Give information to the patient/parent/carer and the need to report problems, about the potential side effects of transfusion such as anaphylaxis which may present as shivering, flushing, shortness of breath, pain in loins or feelings of agitation.
To establish positive identification. To prevent any reactions. Give patient/parent/carer information leaflet to read to enable them to have a full understanding of the procedure (Essence of Care, DOH 2001)6. Patient/parent/carer informed about potential hazards of transfusions and report early indications or reactions
2
Medication Preparation a) Under no circumstances are drugs
to be added to any blood component / product.
b) If Paracetamol, Chlorphenamine or Hydrocortisone to be given as cover prior to transfusion or in the event of a transfusion reaction occurring this must be prescribed by the doctor prior to transfusion commencement.
c) Check that the component/product
has been prescribed on the Transfusion Record to ensure correct transfusion of blood products.
d) Do not prime giving sets with normal saline 0.9%. Do not flush giving sets post transfusion with normal saline 0.9%.
To comply with professional standards of practice. To ensure correct transfusion given.
20
No Action Rationale
2
Medication Preparation (continued) e) Blood must be prescribed on a
Prescription Chart or Transfusion Record (TR) that contains the patient’s ID number, surname, first name and date of birth.
f) The prescription must state the name of the blood component/ product to be transfused, the volume to be transfused, rate of transfusion.
g) A unit of red cells is usually given over a minimum of 1 hour and a maximum of 4 hours.
h) A unit of platelets or FFP is given over 30 minutes.
3
Cannulation or Central Venous access
a) Cannulate the patient according to Cannulation Policy. Ensure cannula is patent.
b) The choice of cannula used for the procedure should be depend on the individual and the desired rate of infusion.
c) Assess the need to flush the cannula (using a pulsating flush) according to policy, prior to transfusion and following procedure.
d) Secure with non-allergic tape or IV dressing depending on choice of cannula.
e) Ensure cannula is well secured.
Appropriate cannula is used and individual patient needs addressed. To keep cannula patent and therefore stop blocking. Reduces the need for extra trauma to the patients. To avoid blood wastage if access unobtainable.
4
Baseline Observations
a) Take the patient’s temperature, pulse, respiratory rate and/oxygen saturation and blood pressure prior to transfusion commencing.
b) Document on Observation chart or specific Transfusion Record. If using ordinary observation
chart highlight that the vital signs correspond to those recorded during a blood transfusion
To have baseline vital signs recorded and ensure that the patient is fit for transfusion.
21
5
Collection or receipt of blood component
a) To collect any blood component the person doing the collection must take four points of patient identification (PID):
• Forename
• Surname
• DoB
• Hospital number/NHS number
b) The nurse requesting the collection must provide the person delegated to collect the component with the four points of patient identification.
22
Checking the blood component
No. Action Rationale
1 Formally identify the patient and ensure that the information matches the Transfusion Record.
2 Check that the 14 digit number on the bar-coded National Blood Service (NBS) label matches the compatibility tag (CT) (luggage tag label attached to the bag).
The correct unit of blood will be given.
4 Start time of unit must be recorded on peel off section of CT, once the first few mls have been transfused.
5 The third section of compatibility tag (CT) needs to be torn off and completed once the transfusion has started ideally when doing the 15 minutes observation post commencement.
6 The third section must be returned to the blood transfusion lab. This is a legal requirement under the Blood Safety and Quality Regulations 2005.
Vein to vein traceability
7 Fill in the time of arrival of blood component/product in clinical area.
Tracking of blood from Blood Bank to recipient.
8 Each blood component/product must be inspected for defects prior to their infusion. Particular attention should be paid to the following
a) Integrity of pack b) Discolouration c) Presence of clots
Faulty products will not be infused.
23
Transfusion of platelets
No. Action Rationale
1 Transfusion of platelets should be commenced as soon as possible following collection/receipt in the clinical area.
This component is used to stop bleeding.
2 Always administer platelets before a red cell transfusion
Platelets are given first in the blood transfusion process as they act to stop bleeding.
3 Platelets are stored at room temperature (Ideally 22 oC but can be between 20-24). Platelets should never be stored in a refrigerator
Preserve the maximum activity of platelets
4 If possible use a platelet giving set.
These giving sets are shorter and it maximises the volume infused, therefore there will a better increment and it is more cost effective.
5 Agitate platelets before administering.
To prevent clumping.
6 Platelets are administered rapidly over 30 minutes. Carry out visual observation for rashes, level of consciousness and change in respiratory rate. Monitor temperature, pulse and blood pressure as for blood transfusion.
As platelets are delivered rapidly, a reaction is possible.
7 Proceed as for blood transfusion. Platelets are more likely to react than red cells because of the temperature at which they are stored.
24
Transfusion of FFP
No. Action Rationale
1 Transfusion of FFP should be commenced as soon as possible following collection/receipt in the clinical area.
This component is used to stop or avoid bleeding by correcting the INR.
2 Always administer FFP before a red cell transfusion
FFP are given first in the blood transfusion process as they act to stop bleeding.
3 FFP should be returned to the BTL within 30 minutes if it is not going to be transfused.
Preserve FFP up to 24 hours, reduces wastage
4 Use blood component giving set.
It has the correct filter
6 FFP is administered rapidly over 30 minutes. Carry out visual observation for rashes, level of consciousness and change in respiratory rate. Monitor temperature, pulse and blood pressure as for blood transfusion.
As FFP is delivered rapidly, a reaction is possible.
7 Proceed as for blood transfusion. FFP are more likely to give an allergic reaction owing to plasma proteins.
25
Transfusion of red cells
No. Action Rationale
1 Transfusion must commence no longer than 30 minutes after delivery to the ward area.
Maximum time of transfusion 4 hours from time out of fridge. Avoid wastage
2 The red cells can only be used for the person who is named on the compatibility tag.
3 If time out of the refrigerator is uncertain it must not be transfused but returned to the BTL and the staff informed.
Risk of bacterial contamination
4 All blood components/product must be transfused through a sterile blood product giving set which has 170-200 micron filter.
To filter micro-aggregates and prevent the accumulation of clots in the filter. This is why a giving set must never be flushed post transfusion. It increases the risk of clots and adverse reactions.
5 The first 15 minutes of a red cell transfusion should be transfused at a slower rate than the prescribed rate. Approximately 20 drops per minute.
Most moderate to severe reactions will occur in the first 15 minutes of a transfusion.
6 Set the rate of the transfusion to 30 – 40 drops per minute for 1 unit of blood to be administered over 2 hours.
To ensure correct delivery rate.
PATIENT MONITORING
No. Action Rationale
1 Patients who receive transfusion should be monitored throughout the whole process (BCSH, 1999)
Risk of reactions.
2 Ensure that the patient is in a setting where they can be closely observed and they can access the nurse call bell.
3 Advise and encourage your patient to notify you immediately if they begin to feel anxious, or if they become aware of any adverse reactions such as shivering, flushing, pain or shortness of breath.
26
4 Monitor the patient’s temperature, pulse
resp. rate and blood pressure 15 minutes after you begin the transfusion of each unit, and record them on the Transfusion record.
Care of patient being transfused
5 Once transfusion is completed record post transfusion observations prior to the removal of the cannula.
6 Once cannula is removed and site secured, discard line in a yellow clinical waste bag, according to clinical waste procedures.
Safe disposal of waste.
7 Discard the blood bag in this way unless there has been a reaction. If there has been a reaction see page 27
8 Complete documentation recording the date and time transfusion ended.
Good record keeping is the mark of a skilled practitioner. (NMC,2002 Continue patient observation.
27
Procedure for reporting adverse reactions
An acute haemolytic transfusion reaction is almost always due to ABO incompatibility. The most likely cause of such an incompatibility is patient mis-identification by persons involved in the transfusion process. Action for all suspected reactions ALWAYS:
No. Action Rationale 1 Stop transfusion immediately. To prevent further reaction.
2 Check the patient’s identity
(verbally and/or ID wristband) to
the compatibility tag attached to
the unit.
Right blood Right Patient
3 Check unit label to compatibility
tag.
Right blood Right patient
4 Get prompt medical evaluation
Assess patient
Types of reactions
No. Action Rationale
1 REACTIONS MILD (Acute) Signs and symptoms Usually occur within the first 15 minutes of each unit. A. temperature – a rise of 1.5 °c above a patient’s baseline is identified as pyrexial. Give Paracetamol dose should be calculated on the patient’s weight to be effective. Encourage patient to drink cold fluids. Keep cool, sponge down as necessary. Contact Medical Practitioner B. urticaria rash (hives) Contact the Medical Practitioner Chlorphenamine should be
Stop transfusion Get prompt medical assessment. To reduce severity of reactions. If signs and symptoms subside or do not get any worse, restart transfusion at a slower rate but continue to monitor / observe patient closely.
28
administered. Dose will depend on the age of the child.
2. MODERATE TO SEVERE (Acute) Burning sensation along the vein, while blood is being transfused. Shock. A feeling of faintness, loss of consciousness, hypotension, chest pain, loin pain, bronchospasm and breathlessness. A rise in temperature, urticaria, tachycardia, rigors and haematuria. Leave cannula in for venous access. Give Epinephrine dose will be age dependent (see local anaphylaxis protocol) Check airway, breathing and circulation. Commence CPR if indicated.
Stop transfusion Get prompt medical assessment For fluid infusion.
3 Infective Shock (Moderate to Severe – Acute) Bacterial contamination of Platelets or, less likely, red blood cells. Usually occurs with the first 100mls of contaminated pack. Signs and Symptoms
• Myalgia
• Shocked patient
• Hypotension
• Rapid pulse
• Raised temperature
• Rigors
• Possible wheeze / dyspnoea Action
• Stop transfusion immediately
• Inform Medical Practitioner
• Treat for shock
• Administer 100% Oxygen via a re-breathe bag.
• Treatment includes prompt medical attention for septicaemia
Stop transfusion To ensure no further blood component is transfused. The smallest amount of blood component will cause a reaction.
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No. Action Rationale
4
Transfusion-related Lung Injury This occurs when donor plasma contains antibodies to the patient’s white cells. Extremely rare but may be life threatening. Occurs during or soon after transfusion. Signs and Symptoms
• Acute respiratory reaction with fever, cough, wheeze / dyspnoea
• Pyrexia
• Tachypnoea Action
• Stop infusion
• Aim to keep patient relaxed
• Inform Medical Practitioner
• Treat as per shock patient
Stop transfusion. Patient will require intubation. To ensure no further blood component is transfused. The smallest amount of blood component will cause a reaction.
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Procedure following reactions
Re-check transfusion documentation and inform BTL:
Return blood bag and giving set to BTL plus any empty bags already used. RETURN ALL UNUSED UNITS Blood samples will need to be taken from the patient:
• 1 cross-match sample
• 1 EDTA
• 1 Sodium citrate
• 1 Heparin
• 1 clotted
• Cultures if there is pyrexia
Ensure that the adverse reaction part of the transfusion record is completed and return a photocopy of the Transfusion Record along with the above to BTL immediately.
To establish any errors in patient identification. To alert BTL of the possibility of another patient being involved in the mismatch. Blood is required by BTL for re-analysis, if possible. Take appropriate blood samples from patient. Information required for investigation.
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Appendix 1: Equipment Required for Transfusion 5
Cannulae / Venous Access Devices
Any size cannula can be used for transfusing blood products but choice must depend on the size of the vein and the speed at which the product is to be given. Recommendations: The needle diameter for transfusion of blood in adults is 18-19 gauge. Needles as small as 23 gauge can be used in paediatric practice.
Blood Giving Sets / Blood Administration Sets
• Do not prime the giving set with Sodium Chloride 0.9%.
• If platelets and red cells are to be transfused give platelets first.
• Do not transfuse platelets through a giving set that has previously been used for red cells or other blood component as this may cause aggregation and retention of platelets in the line.
• It is strongly recommended that platelet- giving sets be used because they are shorter and less platelets are left in the line at the end of a transfusion.
• Red cells and FFP MUST be transfused through a sterile giving set designed for this procedure with integral mesh filter 170-
200µm pore size.
• A screen filter should be used for paediatric patients if the transfusion is being administered by syringe. The filter (170µm pore size) is placed between the product bag and the syringe.
• Giving sets with burettes should not be used for the transfusion of blood components /products.
• All giving sets should be primed with the blood product being transfused.
• If there is another red cell unit to follow of the same ABO group the same giving set can be used.
• If blood of a different ABO group is to follow the giving set must be changed.
• For patients requiring ongoing transfusion, the giving set should be changed at least every 12 hours.
• On completion of the transfusion take down the giving set. Do not flush the giving set with Sodium Chloride 0.9%.
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• A new giving set should be used if any other type of I.V. infusion is to continue after the blood transfusion.
• The cannula or central venous line must be flushed with Sodium Chloride 0.9% prior to commencing any further infusions.
Infusion Pumps
Infusion pumps can be used to achieve optimal flow rate.
• All paediatric red cell and FFP transfusions are administered via a volumetric infusion pump.
• When using any pump it is important to ensure that the giving set is compatible with the volumetric pump.
Pressure devices
In large volume transfusions, the use of a pressure device is recommended. The maximum pressure that should be applied to a blood transfusion pack is 300mmHg.
Blood Warmers
Blood should only be warmed using a specifically designed commercial device with a visible thermometer and audible warning alarm. The manufacturers instructions must be followed.
Blood must not, under any circumstances, be warmed using any other measures.
Blood warmers are indicated if:
• The flow rate is >15 ml/kg/hr for children and for exchange transfusion in infants.
• The patient has severe cold agglutinin disease where cold agglutinins may be clinically significant.
NOTE: For Intrauterine Transfusions (IUT), blood is drawn into 20ml syringes using a filter or via a blood component giving set, which already has an incorporated filter, and allowed to reach room temperature for 30 minutes before infusion. A specific blood warmer is not used.
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Appendix 2: Adverse Reactions to a Blood Transfusion 5
If a transfusion reaction is suspected the transfusion must be stopped
immediately and the patient assessed.
Action for all suspected reactions:
1. Stop the transfusion.
2. Check the patient’s identity (verbally and/or ID wristband) to the
compatibility tag attached to the unit.
3. Check the 14 digit donor number on the unit label to the 14 digit on
compatibility tag. They should be identical.
4. Get prompt medical evaluation
Recognition of an acute adverse reactions Acute adverse reactions occur during the transfusion commonly within the first
15 minutes from commencement of any unit.
Types of Acute Reactions MILD - not life threatening, there can be signs of urticarial rash and/or a
temperature rise of less than 1.5°C above baseline. To treat the urticarial rash give 10 mg of Chlorphenamine as a slow intravenous bolus. To treat the temperature give paracetamol
If the patient does not get any worst or symptoms subside the transfusion can
be re-commenced but at a slower rate of infusion. It is important to monitor
the patient more frequently. The reaction must be documented in the
patient’s medical notes.
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MODERATE TO SEVERE – are those that compromise the patient’s condition and require immediate attention.
1. ABO incompatibility or Haemolytic Reaction (OHR)
Signs and symptoms: Chills, restlessness/agitation, pain at infusion
site, Muscle in abdo/chest/lumbar region, oliguria and anuria (reduced
or no urine output), Haemoglubinuria.
Treatment: Give Furosemide if urine output falls/absent. Treat DIC
with appropriate blood components.
2. Severe allergic reactions
Signs and symptoms: Bronchospasm, angioedema, abdominal pain,
hypotension, oedema – general/local, uticaria rash, facial flushing,
dyspnoea
Treatment: Give Chlorphenamine*
Commence O2 and Salbutamol* nebulizer if necessary
If severe hypotension give Adrenaline*
* Dose will depend on the child’s age
3. Bacterial contamination
Signs and symptoms: Pyrexia, Nausea and vomiting, uticarial rash,
facial flushing, tachycardia, hypo/hypertension
Treatment: Oxygen, Fluid support (IV) Commence broad spectrum
antibiotics
4. TRALI(Transfusion Related Acute Lung Injury)
Signs and symptoms: Dyspnoea, Severe SOB
Treatment: Give 100% oxygen and ventilate if hypoxic
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5. Fluid overload
Signs and symptoms: Pulmonary oedema, SOB, hypertension,
generalised oedema
Treatment: Give furosemide and reduce fluids
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Appendix 3:
Final check with patient present
Jane Doe
22/03/2007
Hosp No2658970
Step 1: Check 14
digit donation
number to Unit
Identification
Label, if they
match
Step 2: Check patient
information on Unit to
Identification Label
to patient’s ID
wristband, if the
information matches
Step3: Transfuse
Individual checking by two authorised persons
Traceability
Section 1: Remains attached to the Blood Bag
Section 2: After final bedside check and commencing transfusion - sign, fill in start
time & date, then affix peel of label to Patient’s TR
Section 3: It is
recommended that this section of the CT be torn off,
as soon as the infusion begins.Remember to sign, print
name, date and time before placing in collection folder
GO54 708 151 567 E
2658970
Jane DoeN 1 22/03/1956
A Rh(D) pos
GO54 708 151 567 E
Comp A Rh(D) pos2658970
2658970
Packed red cells
GO54 708 151 567 E
GO54 708 151 567 E
2658970
Jane DoeN 1 22/03/2007
A Rh(D) pos
GO54 708 151 567 E
Comp A Rh(D) pos2658970
2658970
Packed red cells
GO54 708 151 567 E
‘Final Fate of every unit needsto be recorded by the BTLab’
Section 1: Remains attached
to the Blood Bag
Section 2: After final bedside
check and commencing
transfusion - sign, fill in start
time & date, then affix peel of
label to Patient’s TR
Section 3: This section of
the Identification tag must
be torn off, as soon as the
infusion begins & returned to
the BT Lab via the collection
folder
Remember to sign, print
name, date and timeReturn to
Lab
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Fill in patient’s hospital number
Fill in patient’s: Hospital number
DoB
Full name
Emergency O negative red cells
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MCQ
1. The patient is two years old and requires a red cell transfusion. How would
you identify the patient? Choose the correct answers
a) Ask the parents/carers the child’s full name and date of birth (DoB) b) Look at the patient’s wristband c) Ask another nurse d) Look at the patient’s medical notes
2. If the patient’s DoB is incorrect. Choose one correct answer
a) Begin the transfusion and then inform the BTL b) Put the unit in the ward fridge and then ring the BTL for instructions. c) Return the unit to the blood bank immediately d) Transfuse and document the discrepancy
3. Choose one correct answer. Red cells are transfused to…
a) Increase the circulating volume b) Stop bleeding c) Treat anaemia d) Treat infections
4. The maximum time for a red cell transfusion is…
a) 60 minutes b) 2 hours c) 3 hours d) 4 hours
5. FFP is usually transfused over…
a) 3 hours b) 30 minutes c) 60 minutes d) 10 minutes
6. Platelets are usually transfused over….
a) 60 minutes b) 2 hours c) 3 hours d) 30 minutes
7. The above components can be prescribed …
a) Over the telephone b) Written prescription c) During the ward round, verbally
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8. If you know the patient they need not wear an ID wristband during the
transfusion. True or False 9. The final check before transfusion can take place in the treatment room.
True or False 10. Blood components can be administered through a…..
a) Fluid giving set b) All red blood cells must be given through a blood warmer c) Blood component giving set d) Through a blood component giving set and a pump
11. Before transfusing a blood component it is important to….
a) Weigh the unit first b) Weigh the patient before the transfusion c) Check the unit for leaks, discolouration and date of expiry d) Check that the unit has a bar-coded label
12. All prescriptions must include a transfusion rate and doctors signature.
True or False 13. Daniel’s blood group is A Rh D positive and he requires a platelet
transfusion. Choose a suitable/compatible component.
a) A Rh D negative b) B Rh D positive c) O Rh D positive d) AB Rh D negative
14. It is possible to transfuse Rh D negative components to Rh D positive
patients. True or False
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Glossary Blood component: Red Cells, Platelets, Fresh Frozen Plasma, Cryoprecipitate, White Cells Blood Product: Any therapeutic product derived from human whole blood or plasma donations Cross-match: Laboratory test used to find compatible or suitable allogenic blood (donor blood) for transfusion to a patient/recipient. Febrile non-haemolytic: Fever or rigors during red cell or platelet transfusion affect 1-2% of recipients, mainly multi-transfused or previously pregnant patients, although these reactions are probably less frequent with leucodepleted components. Features are fever (>1°C above baseline) usually with shivering and general discomfort occurring towards the end of the transfusion or up to 2 hours after it has been completed. Most febrile reactions can be managed by slowing or stopping the transfusion and giving an antipyretic e.g., paracetamol (not aspirin). These reactions are unpleasant but not life-threatening. Group & Screen: Laboratory test to identify the patient’s ABO and Rh D blood group and screen for antibodies. Haemoglobin count: Laboratory diagnostic test to identify the amount of Haemoglobin in a person’s blood. Satellite Blood Bank; A refrigerator which stores cross-matched blood but is situated away from the BT laboratory e.g. by theatres or in the Emergency Deprtment. Serious Adverse Events; Any untoward occurrence associated with the collection, testing, processing, storage and distribution of blood and blood components that might lead to the death or life threatening, disabling or incapacitating conditions for patients or which results in, or prolongs, hospitalisation or morbidity. Serious Adverse Reactions; Any unintended response in a donor or recipient that is associated with the collection, testing, processing, storage and distribution of blood and blood components that is fatal, life threatening, disabling or incapacitating conditions for patients or which results in, or prolongs, hospitalisation or morbidity. SHOT is a voluntary, confidential, anonymous reporting scheme for the notification of serious sequelae of transfusion of blood components or blood products.
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Traceability; means the ability to trace each individual unit of blood or blood component derived thereof from the donor to its final destination, whether this is a recipient, a manufacturer of medicinal products or disposal, and vice versa Transfusion Transmitted Infection (TTI); Blood borne infections e.g. Human Immunodeficiency Virus (HIV), Hepatitis C & B, Syphillis etc. that can be transmitted from donor to recipient via a blood transfusion. variant Creutzfeldt-Jakob Disease (vCJD); A fatal disease which may be transmissible through prions transferred during transfusion of blood products from an infected donor. It is believed to be linked to Bovine Spongiform Encephalopathy (BSE) and affects much younger adults than Creutzfeldt-Jakob Disease (CJD)
1. BSE: A neurological disease of cattle which is generally thought to have caused the incidence of vCJD in humans
2. CJD: A neurological disease that targets the brain which can be fatal
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References
Serious Hazards of Transfusion (SHOT) (2007) 10th Annual Report,
Manchester.
www.shotuk.org
Southampton University Hospitals Trust Blood Transfusion Policy, 2006
Department of Health (2005) The Blood Safety and Quality Regulation (No 50) www.opsi.gov.uk
Serious Hazards of Transfusion (SHOT) (2005) 8th Annual Report,
Manchester.
www.shotuk.org
Handbook of Transfusion Medicine, Ed DBL McClelland, 4th Edition, United
Kingdom Blood Services
www.transfusionguidelines.org.uk
British Committee for Standards in Haematology (1999) ‘Guidelines for the
administration of blood and blood components and the management of the
transfused patient’, Transfusion Medicine, 9 (3) pp 227-238.
www.bcshguidelines.com
British Committee for Standards in Haematology (2004) ‘Transfusion
guidelines for neonates and older children.
www.bcshguidelines.com
Department of Health (2001) Essence of care, HMSO, London. Nursing and Midwifery Council (2002) The Code of Professional Conduct.
