QUICK REFERENCE GUIDE



TRANSFUSION POLICY (ADULT)Version10Name of responsible (ratifying) committeeHospital Transfusion CommitteeDate ratified06 July 2018Document Manager (job title)Transfusion PractitionerDate issued02 August 2018Review date05 July 2021 Electronic locationClinical PoliciesRelated Procedural DocumentsPatient Identification Policy; Consent to Examination and Treatment Policy; Management of Adverse Events and Near Misses; Management of Serious Incidents Requiring Investigations; Massive Transfusion (Haemorrhage) Guideline; Policy for the Care of Patients Who Wish to Decline TransfusionsKey Words (to aid with searching)Blood; Platelets; Red Cells; Adverse Transfusion Reactions; Administration; Observations; Blood Components; Administration Sets; Plasma; Blood Transfusion; Consent; Blood Warmers; Jehovah’s Witnesses; Religious Beliefs; Training;Version TrackingVersionDate RatifiedBrief Summary of ChangesAuthor1006/07/2018‘Blood’ removed from title; Indication codes updated; Platelets and frozen components now included (adapted from guidelines on pharmacy pages); Consent sticker now mandatory; “Should” changed to “Must” throughoutK Heron / Sue Chambers922/04/2016Title. Minor adjustments throughout. Indication Codes; Special Requirements; Consent Sticker; Written Instruction and Observation Sheet; Flyer Information; Reaction Flow Chart. K Heron / Sue Chambers826/10/2012-J HickeyCONTENTS TOC \o "1-2" \h \z \t "Appendix,1,Heading,2" QUICK REFERENCE GUIDE PAGEREF _Toc520116046 \h 31.INTRODUCTION PAGEREF _Toc520116047 \h 52.PURPOSE PAGEREF _Toc520116048 \h 53.SCOPE PAGEREF _Toc520116049 \h 54.DEFINITIONS PAGEREF _Toc520116050 \h 65.DUTIES AND RESPONSIBILITIES PAGEREF _Toc520116051 \h 66.PROCESS PAGEREF _Toc520116052 \h 87.MANAGEMENT OF ADVERSE TRANSFUSION REACTIONS PAGEREF _Toc520116053 \h 148.RAPID INFUSIONS AND BLOOD WARMERS PAGEREF _Toc520116054 \h 169.STORAGE PAGEREF _Toc520116055 \h 1610.USE OF PLATELETS PAGEREF _Toc520116056 \h 1611.USE OF FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATE PAGEREF _Toc520116057 \h 1912.TRAINING REQUIREMENTS PAGEREF _Toc520116058 \h 2013.REFERENCES AND ASSOCIATED DOCUMENTATION PAGEREF _Toc520116059 \h 2014.EQUALITY IMPACT STATEMENT PAGEREF _Toc520116060 \h 2115.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS PAGEREF _Toc520116061 \h 22APPENDIX 1: Indication Codes for Transfusion PAGEREF _Toc520116062 \h 23APPENDIX 2: Blood Transfusion, Size Matters! PAGEREF _Toc520116063 \h 26APPENDIX 3: Consent for Transfusion PAGEREF _Toc520116064 \h 28APPENDIX 4: Written Instruction PAGEREF _Toc520116065 \h 29APPENDIX 5: Blood Component Specific Requirements PAGEREF _Toc520116066 \h 31APPENDIX 6: Emergency Blood Issue PAGEREF _Toc520116067 \h 33APPENDIX 7: Acute Transfusion Reactions (ATR) PAGEREF _Toc520116068 \h 34APPENDIX 8: Common Complications Associated with Transfusion of a Blood Component PAGEREF _Toc520116069 \h 35APPENDIX 9: Modified WHO Bleeding Score PAGEREF _Toc520116070 \h 37EQUALITY IMPACT SCREENING TOOL PAGEREF _Toc520116071 \h 38QUICK REFERENCE GUIDEFor quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. Obtaining consent for all transfusions is a Department of Health requirement and is the responsibility of the Clinician or Non-Medical Authoriser making the decision to transfuse. Do not forget the rights of the competent patient to refuse a transfusion or request an alternative treatment, if available. Transfusion Patient Information Leaflets are available and must be offeredTransfusion written instruction (prescription) must include four patient specific identifiers: surname, first name, date of birth and NHS number. If patient has no NHS number write on request form “NHS number not available” and use Casenote/Hospital/PAS number. For “unknown” patients (primarily ED) use ED number, unknown and gender. Type of blood component, specific requirements (e.g. CMV negative, irradiated etc.), quantity to be given, duration and rate of infusion, name and signature of Clinician or Non-Medical AuthoriserOnly suitably trained registered practitioners can request blood and blood components. Request forms must contain the four markers of patient identification (PID) as above, together with the reason for transfusion (Indication Code, appendix i, page 24), date and time required, name and signature of requesting Clinician or Non-Medical Authoriser, and the locationOnly suitably trained staff may take samples for group and screen and cross-matching. The sample must be taken into an EDTA (pink top) tube. These must be correctly labelled by hand, beside the patient, from the PID band (inpatients), with the four points of ID and they must be dated, timed and signed. All samples must be labelled by the staff member who took the sampleWhen a cross-match is requested and the patient does not have a historical group recorded on the Apex (LIMS) computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the group has been verified. Whilst there is no time specification between the two samples, they MUST NOT be taken at the same time. Ideally taken by a different practitioner and must be sent with a separate request formA consent sticker (appendix iii, page 29) must be used to document, that the process of gaining informed consent has taken placeAll staff collecting blood and blood components must have initial training then annual revalidation. All staff are responsible for ensuring their training needs have been met. Before collecting the blood or blood component, ensure the patient is ready to receive the transfusion and has the correct PID band in situ. When collecting blood or blood components, staff must check the four specific points of PID (as above) they have brought with them against the component label before scanning it out of the issue fridge or signing for it from within the Transfusion Laboratory (any discrepancies must be reported to a member of the Transfusion Laboratory staff immediately)Blood and blood components must be commenced, or returned to the Transfusion Laboratory within 30 minutes from collection Before administration the specific four points of PID (as above) must be checked against the component label and the PID band at the side of the patient. Do not connect any components unless you have checked all the details are correct yourself (any discrepancies DO NOT GO AHEAD, report to Transfusion Laboratory staff immediately)Transfusions must be given in clinical areas, where frequent visual and verbal contact with the patient may be maintainedAs a minimum per unit, the conscious patients’ temperature, pulse, respiratory rate (TPR), blood pressure (BP) and oxygen saturations (O2 Sats) must be checked before the start of the transfusion, 15 minutes following the start of the transfusion and again at the end of the unit. The unconscious patient requires, as a minimum per unit, TPR, BP and O2 Sats before the unit is started, every 15 minutes for the first hour and hourly thereafterBlood and blood component labels must be fully completed. As indicated, one must be returned to the Transfusion Laboratory and one fixed to the patients’ transfusion written instruction/notesPatients must be encouraged to inform a member of staff if at any time during the transfusion they feel unwell (day case patient information leaflets to be given on discharge, available to order from Medical Illustration ref: 14/5879)A giving set used for a blood transfusion must NOT be subsequently used for administering fluids or different blood componentsAccurate documentation of the transfusion must be maintained Any suspected adverse reaction(s) or events should be communicated to the Transfusion Laboratory staff and/or to the Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE) and a Datix report completedBlood and blood components must NOT be stored in a ward domestic or drug fridge UNDER ANY CIRCUMSTANCERoutine transfusions may be administered overnight, providing the environment is conducive to safe practice enabling close visual monitoring of and verbal communication with the patient and all observations to be carried out and recorded as per this policy. However, if the transfusion could safely wait until the day time then this would be preferable. TRANSFUSIONS MUST TAKE PLACE OVERNIGHT IF THE PATIENT IS BLEEDING OR SYMPTOMATICUse of Platelets, page: 19 Use of FFP and Cryoprecipitate, page: 21INTRODUCTIONAppropriate transfusion is an essential support to many medical treatments and can be lifesaving. There are many risks to the patient, including acute haemolytic reactions and transfusion transmitted infections. Incidents affecting the safety of transfusion are highlighted through the Serious Hazards of Transfusion (SHOT) haemovigilance scheme. This scheme has shown that avoidable, serious hazards of transfusion continue to occur in Trusts throughout the UK, the most frequent factor being human error. Out of 3091 total reported incidents, 87% were caused by human error (often multiple errors). There has been little progress in the last decade (Annual SHOT Report 2016, July 2017).Stringent procedures must be followed to ensure that the correct blood/blood component is always given and that any adverse reactions are dealt with promptly and efficiently.Procedures for requesting, writing up and the administration of blood and blood components, as well as the management of any complications support this clinical policy on transfusion. Procedures for the documentation of transfusions in nursing, medical and laboratory records are also provided, including the procedure for the reporting of any adverse reactions or events occurring in relation to transfusions.This clinical policy has been revised to clarify terminology, incorporating core standards in transfusion practice in adult patients. Neonatal Intensive Care patients are one of the most transfused groups and because of their potential normal life expectancy they are more susceptible to the long-term effects of transfusion. Particular care and attention must be given to neonates and children to minimise blood component use. See local departmental PHT policy for neonatal and paediatric practice. This policy reflects the Blood Safety and Quality Regulations (BSQR) 2005, current NICE guidelines and BSH recommendations. PURPOSEThe purpose of this policy is to:Provide a clear framework and guidance for safe transfusion practice, throughout Portsmouth Hospitals NHS Trust (the Trust)Ensure a consistent approach to the requesting, writing up, handling and administration of blood and blood components throughout the TrustEnsure that all members of staff involved at any stage of the process of transfusing blood and blood components are aware of their role and the legal aspects of this practiceSCOPEThis policy applies to all staff involved in the requesting, sampling, prescribing, storing, collecting, transporting and administering of human blood and blood components, including those who work in Primary Care Trusts supplied with blood/blood components from the Trust Transfusion Laboratory.‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on going patient and staff safety’DEFINITIONSTransfusion: blood or any of its components used to correct or treat a clinical abnormalityBlood component: red cells, platelet concentrate, fresh frozen plasma (FFP), OctaplasLG?, and cryoprecipitate Blood Product: any drug which is manufactured using human blood componentsPatient Blood Management (PBM): a standard of care that focuses on measures to reduce or avoid the need for transfusion if possible. If a transfusion is needed, the aim is to ensure that the patients are only given what they really need and that the transfusion is given safelyCold chain: the legal requirements to monitor transport and storage conditions of blood components, from donor to recipientMaximum Surgical Blood Ordering Schedule (MSBOS): the Trust’s agreed maximum number of cross-matched units or group and screen testing requirements for surgical proceduresMedicines and Healthcare Products Regulatory Agency (MHRA): An executive agency which aims to enhance and safeguard the health of the public by ensuring that medicines and medical devices work and are acceptably safeSerious Adverse Blood Reactions and Events (SABRE): the MHRA reporting scheme to which serious adverse reactions and events related to blood components / products are reportedSerious Hazards of Transfusion (SHOT): the United Kingdom’s independent, professionally-led haemovigilance scheme, responsible for recording and monitoring all blood component adverse events and reactionsSerious Incidents Requiring Investigation (SIRI): Trust system for investigating Amber or Red incidents and eventsDUTIES AND RESPONSIBILITIESThe Hospital Transfusion Committee (HTC)The HTC includes members of the Hospital Transfusion Team and representatives from all clinical areas where blood and blood components are administered. Responsible for: Overseeing all aspects of transfusion practicePromoting good transfusion practice based on national guidelines through the provision of a robust framework to communicate information and advice Arranging for audits of blood and blood component usage to be carried out, in line with local and national requirements and receiving and reviewing the reports of those auditsMaking recommendations to address any issues highlighted by the reports and monitoring the implementation of the actionsReceiving quarterly reports from the Hospital Transfusion Team regarding the trends and themes from adverse incidents, including any variance from this policy and for recommending any actions to address the varianceReviewing all SHOT submissions and ensure the root causes are identified and all necessary action taken to prevent a recurrenceMonitoring the implementation of actions arising from the investigation of SIRIReceiving the results of all audits associated with the transfusion process and developing any required action plans to address the identified issues Undertaking regular review of this policy and recommending any changes as highlighted by audits or adverse incidentsEnsuring any risks associated with the transfusion process are assessed and escalated to the Trust Risk RegisterActing as a forum to discuss advancements in transfusion practice, including PBM and reviewing and amending practices and policies in the light of those advancementsProviding, through the Chair, an annual report on all aspects of transfusion practice, to the Governance and Quality Committee Hospital Transfusion Team (HTT)The HTT includes the Clinical Lead for Transfusion, Transfusion Laboratory Manager (TLM), Transfusion Laboratory Seniors, Transfusion Practitioner (TP) and Transfusion Practice Educator (TPE). Responsible for:Meeting at least once a month to discuss current issues and incidentsAddressing and monitoring any outstanding corrective and preventative actions Informing the decision-making process for new initiativesEnsuring the HTC is informed of any required auditsReporting quarterly to the HTCThe review and development of policies and guidelinesClinical Lead for TransfusionResponsible for:Acting as the main point of contact for medical staff, including GP’s, requiring information, advice and guidance on transfusion issuesSubmission of clinical information to NHSBT to aid investigation of serious adverse transfusion reactions, in conjunction with TP and TPE TLMResponsible for: Ensuring the Transfusion Laboratory complies with the legislation as set down in the Blood and Safety Quality Regulations (BSQR 2005) and the statutory requirements of the Department of Health to ensure patient and staff safetySubmission of reports to SABRE and/or SHOT, in conjunction with the TP and TPEThe investigation of all adverse incidents and near misses associated with any aspect of transfusion, in conjunction with the TP, TPE and Laboratory SeniorsTP and TPEResponsible for:Submission of reports to SHOT and/or SABRE, in conjunction with the TLM and Laboratory SeniorsThe investigation of all adverse clinical incidents and near misses associated with any aspect of transfusionProvide the HTC with quarterly reports on all aspects of transfusion practice, including adverse eventsFacilitate education and training for all relevant clinical staff groupsParticipate in local and national audits and feedback results to HTT and HTCMaintain and update relevant clinical policiesProvide advice and support on transfusion matters to clinical staffClinicians Including Non-Medical Authorisers Responsible for:The decision to transfuse in conjunction with NHSBT indication codes (appendix i, page 24)For stable, non bleeding patients consideration must be made that each unit is a separate clinical decision in conjunction with the potential risk of Transfusion Associated Circulatory Overload (TACO), see appendix ii, page 27The consent process, sticker (appendix iii, page 29) must be fully completed and placed into the patients’ notes. Patient written information leaflets must be offered, these are available from TP and TPE Where practical, informing patients of alternatives to transfusionFull completion of Transfusion Written Instruction (appendix iv, page 30)Ensure any specific requirements are met (appendix v, page 32)All Ward and Line Managers Responsible for: Being aware of this policy and associated policies and guidelinesReleasing staff for trainingIntegrating compliance into the Knowledge and Skills Framework (KSF) and Annual Performance and Development Appraisals (APDR) for all their staffEnsuring appropriate evidence of compliance is gained during the APDR processEnsuring their staff are aware of and understand this policy and comply with its content Communicating any concerns regarding staff compliance with this policy to the TP/TPEAll Staff Involved in the Processes Associated with TransfusionResponsible for:Being aware of this policy and associated policies and guidelinesComply with this policy at a level commensurate with their involvementAttending training relevant to their role in the processReport all adverse events and near misses on Datix to enable investigation/monitoring by TP/TPEPROCESSNote: whilst the same principles apply to all patients regardless of age, there are some very specific issues which relate to neonates and paediatrics, see local PHT departmental guidelines. For renal patients see speciality guidelines and policies, WRTS Blood Administration: Adults on Haemodialysis/Haemofiltration.ConsentObtaining consent for a transfusion is a Department of Health requirement and it is the responsibility of the prescribing Clinician or Non-Medical Authoriser to obtain and document that consent in accordance with Trust Policy and provide written information (leaflets available from TP and TPE). If the patient is unable to provide consent, this must also be documented in the notes. Refer to the Trust ‘Consent to Examination and Treatment Policy’. In order to facilitate the documentation of consent, stickers must be used, these are available from Medical Illustration and must be completed and placed in the patients’ notes (appendix iii, page 29)Where practical, patients must be informed of the reason for the transfusion, the potential risks and benefits involved. They should also be informed of their right to refuse the transfusion but must then be advised of the risks of doing soAll staff, but particularly those taking consent must be aware:Of the beliefs of the Jehovah’s Witness in relation to receiving any blood component and medical alternatives, which may be applicableThat an individual patient may accept different treatments such as dialysis, cardiopulmonary bypass, organ transplants, and non-blood replacement fluids of plasma derivatives, iron therapy and cell salvageThat any patient may have valid personal reasons or beliefs for not wishing to have a transfusionThat each patient has the right to be treated with respect and staff must be sensitive to their individual needs, acknowledging their values, beliefs and cultural backgroundThe patient must be provided with information about alternatives to transfusion, where appropriate, including autologous transfusionIn circumstances where a patient lacks the capacity to consent and it is an emergency or urgent situation, treatment can be provided on the basis of ‘best interests’. There is a tick box to indicate this on the consent sticker and also a patient information leaflet available for patients who have received an unexpected blood transfusion (obtain from TP and TPE) In elective situations the healthcare professional seeking consent must consider whether the patient has put in place a valid and applicable Advanced Decision, which covers the refusal of a transfusionFor guidance regarding religious or personal beliefs refer to the Trust’s Policy on the Care of Patients Who Wish to Decline TransfusionsFurther guidance can be obtained from the Trust’s Legal Services ManagerBlood SamplingOnly suitably trained and competent staff may perform phlebotomy for group and antibody screen and cross-matchingAll blood samples must be taken in accordance with Trust Policy (refer to Blood Sampling Policy (Adults)The sample must be taken into an EDTA (pink top) tube and immediately labelled at the side of the patient by the staff member who took the sample. The sample must be labelled appropriately, with the specific four points of PID – Surname, First name, DOB, NHS number and be dated, timed and signed. No amendments acceptedPre labelled tubes and addressograph labels MUST NOT be usedWhen a cross-match is requested and the patient does not have a historical group recorded on the Apex computer system, the Transfusion Laboratory staff will request a second sample. This will NOT cause a delay in obtaining blood for the patient when blood is required urgently. The patient will receive group ‘O’ until the second sample has been verified. Whilst there is no time specification between the two samples, they MUST NOT be taken at the same time. Ideally taken by a different practitioner and must be sent sent with a separate request formSamples are valid for 7 days UNLESSThe patient has been transfused or pregnant in the previous 3 monthsTHEN the sample is only valid for 72 hoursFor planned C-section valid for 96 hoursThese timings include any transfusion timeAll transfusion samples must be labelled by handRequesting Blood and Blood Components For Emergency Issue of Blood or activation of the Massive Transfusion (Haemorrhage) Guideline Call ext: 4444Only suitably trained registered Clinicians and Non-Medical Authorisers can request blood and blood componentsRequest forms must contain the four specific PID identifiers (Forename, Surname, DOB and NHS Number) and include the date and time blood and blood components are required, contact number, clinical details, name and signature. The request may be refused if the form is not completed appropriatelyThe request form must clearly state any specific requirements e.g. CMV negative/ irradiated (appendix v, page 32) For patients who cannot supply the relevant information, the name and date of birth can be verified by the patients’ family, carer, guardian or other representativeRequests for blood and blood components will not be processed if the sample is inadequately labelled as previously stated (i.e. must have the four points of PID, be dated, timed and signed, with no amendments and be legible) Unidentified patients are usually admitted via the ED department. In these circumstances the request form and the sample must be labelled with the identity status of ‘unknown ‘male’ or ‘unknown female’ and ED number If the unidentified patient is a young person who may have been born after 1st January 1996, this must be made known to the Transfusion Laboratory so appropriate components can be issued, until the actual date of birth is confirmedFor non urgent requests the Transfusion Laboratory usually require 48 hours notice to prepare blood and blood components. If required earlier than 48 hours, call the Transfusion Laboratory on ext. 6539 to discuss the requestIndication codes (appendix i, page 24) are a mandatory field when requesting a cross match on ICE and must also be specified where indicated on the hand written request forms Where antibodies are identified, selection of blood may take longer as complex cross-matches may require referral to NHSBT in Bristol for testing and/or the sourcing of antigen negative blood from NHSBTRequests for platelet issue must be made by calling the Transfusion Laboratory, ext. 6539, see table below. Ensure any specific requirements are communicated. All verbal requests must be followed up with an ICE request form printed directly to the transfusion laboratory printer, P062747. Alternatively a hand written form can be sent in the POD system Also Refer to:Use of Platelets, page 19Use of FFP and Cryoprecipitate, page 21Use of OctaplasLG? Guideline within Pharmacy Intranet page. Drug Therapy Guideline No 161.00 Issued: 25.01.13Requests for Elective SurgeryPatients who are scheduled for elective surgery must have a group and antibody screen performed at least 48 hours prior to enable any detected antibodies to be fully identified and blood transferred to siteElective surgery must not be cancelled because of non availability of a group and antibody screen. Suitable units will be made available in the event of an emergencyWritten Instruction and Observation Sheet (prescription) (appendix iv, page 30)Must be completed with the following…..Patient identifiers (addressograph label)Patients body weight, think TACO (appendix ii, page 27)Recent FBC results (inpatients within 24hrs, outpatients within 72hrs)Date to be transfusedBlood (written as ‘packed red cells’) or blood component to be transfused, plus any specific requirements (e.g. CMV negative, irradiated etc.)Each unit must be written individually. Consider single unit (appendix ii, page 28)The duration or rate of transfusion (packed red cells 2 or 3 hrs, platelets, FFP/OctaplasLG? Cryoprecipitate a maximum of 30 minutes)Name and signature of Clinician or Non-medical AuthoriserA new sheet must be used per episode of transfusion (an episode is within a 24 hour period)Collection from the Blood Issue Fridge and the Transfusion Laboratory Before the collection of blood from the issue fridge in Pathology reception, or blood and blood components from the Transfusion Laboratory, staff must check that a written instruction has been correctly and fully completed as aboveIt is a statutory requirement that all staff collecting blood and blood components have initial training and maintain their access by annual revalidation when asked to do soOnly suitably trained, competent and validated staff may collect blood and blood componentsThe member of staff must:Check the patient details on their identity band, notes and written instruction are correctRemember: No Identity Band, No TransfusionEnsure there is a suitable, patent cannula for the transfusion (or central line) – ensuring it has been flushed prior to collecting the unitEnsure your patient is ready and has consented to having the transfusion. Allow time to discuss and alleviate any anxietiesEnsure administration equipment is available (pump, drip stand and appropriate giving set)Take official printed confirmation of the patients’ identity to the issue fridge or Transfusion Laboratory (written instruction or addressograph label). This must contain the four points of PID, this must match the patients’ identity bandFor the issue fridge, swipe their validated ID card to gain access Note: it is a disciplinary offence to use someone else’s cardSelect the unit requiredConfirm the details on the blood compatibility label with the printed confirmation of the patients’ identity (this must also take place if collecting from within the Transfusion Laboratory. For blood components, all these details must also match the paper printout)Scan the unit as demonstrated during training, ensuring the unit number appears on the screenOnly one unit per patient must be removed at a timeTake the unit directly to the clinical area in which it is required, in the red bag provided, make no diversions Start the transfusion immediately on return to the clinical area, do not leave to ‘warm up’Blood and blood components must be either started on the patient or returned to the Transfusion Laboratory within 30 minutes of removal from cold storageIn an emergency or massive haemorrhage situation, (call 4444) a cold box will be issued by the Transfusion Laboratory staff, see ‘Massive Transfusion (Haemorrhage) Guideline’. Two units will be issued in a red bag, to be started on the patient or returned to the Transfusion Laboratory within 30 minutes. Two units will also be issued in a cold box sealed with a cable tie. This will keep the blood safe for up to four hours if the cable tie remains intact, see flow chart appendix vi, page 34.Blood and blood components must NEVER be stored in a ward fridge (domestic or drug)Administration of Blood and Blood ComponentsTo administer and/or check blood and blood components the staff member must be a Registered Practitioner and suitably trained (firstly completed their IV competency) and have a blood administration competency signed to a minimum of level twoMust be in date on ESR with their ‘Blood Awareness Update’ Transfusions must be administered in the clinical area, where frequent visual and verbal contact can be maintainedBlood and blood components can be administered peripherally or centrally, a Y connector must NOT be used. No other fluids must be administered at the same time into the same peripheral cannula. However, if a patient has a double lumen central/PICC line with distal and proximal ports, different fluids can be administered at the same timeNo other drugs or fluid must be mixed with blood and blood components under any circumstancesThe correct giving set must be used for the appropriate blood component and its availability must be confirmed prior to collecting the component. This will prevent any unnecessary delay in starting the transfusionType of ComponentType of setChange Set afterRed Cells*Blood giving set with integral 170-200 micron filter12 hours or 4 units of blood (whichever comes first)Platelets*Blood giving set with integral 170-200 micron filterAfter each unitFresh Frozen Plasma* (FFP)Blood giving set with integral 170-200 micron filterAt the end of the administration Cryoprecipitate*Blood giving set with integral 170-200 micron filterAt the end of the administration*Fresh giving sets must be used with a different component. Do not use the same set for different components as clotting may occurBe pragmatic during an emergency / massive haemorrhage situationRed Cells: must be administered within a maximum of four hours from leaving cold storage. Slower infusion promotes bacterial growth in the unit. Two hours is suitable for most patients however, those patients with underlying cardiac or respiratory conditions may require the transfusion to be given over three hours Be aware of the volume being infused – remember the risk of TACO (Information Flyer Appendix 2)Platelets: Start immediately once received into the clinical area and administer over 30 minutesFFP/Cryoprecipitate: Start immediately once received into the clinical area and administer ‘stat’, maximum 30 minutesOctaplasLG?: As for FFP/CryoprecipitateVolumetric pumps must be used with the appropriate administration setTo reduce the risk of transfusion errors, units must be checked at the patients’ bedside. Remote checking of the unit away from the patient is unacceptable and unsafe. Positive identification of the patient at the bedside is essential and mandatoryEnsure that all PID markers correspond (blood or blood component label, PID band and all other paperwork and documentation) any discrepancies: DO NOT TRANSFUSE and inform the transfusion laboratory immediately: Extension 6359Check unit type matches written instructionIf a patient is conscious, able to communicate and able to actively take part in the checking process, it is recommended that a single Registered Practitioner should check the unit with patient at the bedside. The Registered Practitioner must ask the patient to state their surname, first name, date of birth and confirm spellingAll other scenarios, it is required that two registered practitioners check the unit, independently, at the bedside. If required another member of staff or relative/carer can confirm the patient’s identityIn the event of an “unknown” patient, the PID band, which will include the ED number, unknown male/female should be used for checking purposesRefer to Patient Identification PolicyRemember: No Identity Band – No TransfusionAny discrepancies – DO NOT transfuse, contact the Transfusion Laboratory and return the unit immediatelyThe Registered Practitioner(s) must also check the expiry date of the blood or blood component and ensure the donation number e.g. G…………… number and the blood group on the bag corresponds to the attached printed label. Handwritten amendments to PID are NOT permittedBlood or blood components must never be left unattended or stored in the clinical area under any circumstancesObservations Required for Transfusion (MUST be performed in addition to frequency indicated by VitalPac)Conscious PatientsRecord the patient’s temperature, pulse, respirations (TPR), blood pressure (BP) and oxygen saturations (O? Sats) prior to (collection) starting the transfusionAsk the patient to report if they are feeling unwell in any way during the transfusionRepeat and record the patients TPR, BP and O? Sats at 15 minutes. This is the crucial time, as severe reactions frequently occur during this timeThe recording of further observations and the regularity of those is dependent on the patients’ underlying condition or if the patient becomes unwell, or shows signs and symptoms of a reactionRepeat and record the patients TPR, BP and O? Sats at the end of the unitRegular visual observations of skin colour and cannula site must be undertakenRegular verbal communication throughout the transfusion must take placeFluid balance should be recorded on the ‘fluid balance’ chartUnconscious PatientsIn addition to the observations for a conscious patient:Repeat the TPR, BP and O? Sats every 15 minutes for the first hour and hourly thereafter if patient stableTransfusing at NightIf the patient is bleeding and/or unstable, transfusions MUST always take place overnight Routine transfusions may be administered overnight, providing the environment is conducive to safe practice. Patient safety is paramount. Ensure close visual and verbal monitoring of the patient throughout the entire transfusion episode and all observations must be carried out and recorded as per this policy. However, if the transfusion could safely wait until the following morning, then this would be preferable DocumentationIt must be documented in the patients’ medical notes the reason for the transfusion and where the patient is able, that a conversation has taken place between the prescribing Clinician or Non-medical Authoriser and the patient about the risks and benefits associated with transfusion Consent sticker (appendix iii, page 29) must be used to document informed consent has taken placeThe component type, amount administered and any adverse effectsThe middle traceability label stating ‘Complete and affix this label to transfusion pathway record’ must be filled in appropriately and placed on side two of the written instruction (appendix iv, page 30) Detach the ‘Return to transfusion’ traceability label which must be filled in appropriately with date, time, name and signature of administrator and returned to the Transfusion Laboratory in the envelope provided once the unit is connected to the patient. This is a legal requirement, therefore a Datix report will be entered for all non returned labels or if they are returned but without date and time of transfusion and signatureIn an emergency where administration of ‘emergency group O’ units has taken place, the labels MUST be completed with the details of the patient who received the unit, in addition to the information stated aboveOnce the transfusion episode is completed, the written instruction must be filed in the patients’ medical notes in the appropriate date area of the history sheetsMANAGEMENT OF ADVERSE TRANSFUSION REACTIONS (Flow chart, Appendix 7; Table of common complications associated with transfusion of a blood component, Appendix 8)Patients with severe reactions can deteriorate very quickly with hypotension, respiratory distress, collapse and possible deathRemember single unit transfusions reduce the risk of an adverse reactionAcute Transfusion Reactions (ATRs)Present within 24 hours of transfusion and vary in severity from mild febrile to allergic reactions to life threatening events. They include:Febrile non-haemolytic transfusion reactions – usually clinically mildAllergic transfusion reactions – ranging from mild urticarial to life-threatening angio-oedema or anaphylaxisAcute haemolytic transfusion reactions – e.g. ABO incompatibility Bacterial contamination of blood unit – range from mild pyrexial reactions to rapidly lethal septic shock depending on speciesTransfusion-associated circulatory overload (TACO)Transfusion-associated acute lung injury (TRALI)Possible features of an acute transfusion reaction, which may include, but are not limited to:Patient in distressRestlessness/ behavioural changesPyrexiaChillsRigorsTachycardiaHyper/hypotensionFlushing/pallorHeadache Pain at or near transfusion cannula siteUrticariaAnaphylaxisPain (bone, muscle, chest, abdominal, loin, back)DyspnoeaRespiratory distressNausea/vomitingGeneral malaiseHaemoglobinuria/haematuriaCollapseSuspected Minor ReactionPyrexia of < 2? C from baseline and/or pruritus or rash WITHOUT other features: The transfusion can be slowed down and continued with direct observation and possible treatment with oral paracetamol (adult dose 500-1000mg) and/or antihistamine (adult dose of chlorphenamine 10mg IV). If hydrocortisone is required the standard dose for an adult is 100mg by slow IV injectionIf transfusion is discontinued follow suspected transfusion reaction process as belowSuspected Moderate/Severe ReactionPyrexia of ≥ 2? C from baseline and/or chills, rigors, tachycardia, hyper/hypotension, urticaria, anaphylaxis, chest/back/abdominal/bone pain, dyspnoea, respiratory distress, nausea/vomiting, haemoglobinuria/haematuria, collapseStop the transfusion, call for medical assistance, check PID and unit compatibility label, maintain venous access, resuscitate and treat symptomsReturn implicated unit bag, with giving set, and any previous transfusion unit bags that have been used in this episode to the Transfusion Laboratory Fully complete the ‘Investigation of Suspected Transfusion Reaction’ form (available only from the Transfusion Laboratory) and return promptly to the Transfusion LaboratoryFollow documentation as belowDocumentation of ATRs/IncidentsAll transfusion (including ‘near miss’) incidents and suspected ATRs must be reported on the Trust’s ‘Safety Learning Event’ DATIX system (accessible from desktop icon)TP/TPE will be alerted to transfusion related incidents entered onto DATIX. They will ensure correct process has been followedDocument clearly and concisely in patient’s notes Any ‘wrong blood component in patient’ or other major incident must be recorded as a SIRI and fully investigated in accordance with Trust Policy. Inform TP/TPE ASAPAll ATR’s and any other adverse incidents will be discussed by the HTT and reported quarterly to the HTC SHOT/ SABRE ReportingVarious incidents including moderate/severe ATRs will be reported to SHOT/SABRE as required to by the TP/TPESHOT suggest that TACO and TRALI are under reported. Therefore any suspicion of these, contact the TP (Monday – Friday 0800-1600) and the on-call Haematologist via the Trust switchboardRAPID INFUSIONS AND BLOOD WARMERSThe routine warming of blood is not necessaryWarming the blood increases the risk of bacterial growth, so should not be used except in the following circumstances:Massive haemorrhage where level one infusers are usedNeonates/Infants requiring exchange transfusionPatients who have clinically significant cold agglutinin antibodiesPatients who are hypothermic or at risk of becoming hypothermic due to complicated or prolonged surgeryIf blood is required to be warmed, this must only be completed using a specifically designed commercial device, with a visible thermometer and audible alarm which ensures the blood is not warmed over 410CThe device must be monitored and validated every twelve months. Blood warmers are extremely dangerous if they malfunctionSTORAGEBlood is only to be stored in a purpose built, fully validated and alarmed fridge at between 2 and 60C, in accordance with BSQR (2005). This prevents the risk of bacterial growth. Note: The alarm is connected to the Hospital switchboard to alert of any malfunctionBlood must NEVER be stored in a ward/departmental drug or food fridgeRed cells must be either started on the patient or returned to the issue fridge/Transfusion Laboratory within 30 minutes of removal from cold storageBlood components must be transfused as soon as possible following removal from the Transfusion Laboratory to ensure they are at optimum quality. All unused units must be returned to the Transfusion Laboratory. These components must never be stored at ward/departmental levelUSE OF PLATELETSPlatelet transfusions are an essential component in the management of selected patients with thrombocytopenia. However they need to be used judiciously as they are a limited resource and are not risk-free.BackgroundPlatelet transfusion fall into two broad categories, either ‘therapeutic’, to treat bleeding, or ‘prophylactic’, to prevent bleeding. This is based on the modified World Health Organization (WHO) bleeding score (appendix ix, page 38). Recommendations for prophylactic transfusion relate to patients with bleeding score of 0 or 1 and therapeutic transfusion to patients with bleeding score of 2 or higher.This can be divided into 3 distinct situations.Prophylactic (WHO bleeding score 0 or 1) to prevent bleeding Routine use in non-bleeding patientsIn the presence of additional risk factors for bleeding e.g. sepsis or abnormalities of haemostasisPre-procedure to prevent bleeding expected to occur during surgery/invasive procedureTherapeutic (WHO bleeding score ≥2) to treat active bleedingIndications for the use of Platelet transfusion appendix i, page 25.Standard available platelets can be apheresis (single donor) or pooled (multi donor). This does not affect their usage or efficacy.Certain specialised products are available after discussion with a Haematologist. These include HLA matched platelets, Irradiated platelets (appendix v, page 32), neonatal or intrauterine components.Platelets are kept at room temperature and therefore have a short shelf life - currently 5 days although recently some units are given a 7 day shelf life. A single unit is usually adequate for prophylaxis. One adult therapeutic dose (ATD) should give a rise in platelet count of 20 – 40 x 109/L.Infection is a major risk in transfusing platelets. Much of this risk is because they are kept at room temperature. Requirements for issuing PlateletsKnown Blood group recorded on Laboratory Computer.Thrombocytopenia with no contraindication for use of plateletsIssue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automaticContraindication to Transfusion of Platelets.Thrombotic Thrombocytopenic Purpura (TTP)Can make TTP worse so are contraindicated unless haemorrhage is life threatening. BSH guidelines on TTP should be consulted for these rare patientsHeparin Induced Thrombocytopenia (HIT)This thrombocytopenia is associated with severe thrombosis. Heparin should be withdrawn, including IV flushes and low molecular weight heparin. Platelet transfusion is contraindicated. Platelets aggregate with heparin – giving platelets can drive this aggregation and can cause arterial thrombosisOrdering platelets from the Transfusion LaboratoryThe Transfusion Laboratory hold a limited supply for emergency use only. The short shelf life means they are only supplied at the time they are required. The laboratory has a stock rotation policy to reduce wastage Full patient identifiers and known blood group are required. If no blood group is known, and is not recorded on the laboratory computer, a group & screen sample must be sent with the orderThe approval of a haematologist is required to ensure appropriate usage, with the exception of DCCQ and NICURequests for platelets must be made by calling the Transfusion Laboratory, ext. 6539, see table below. Ensure any specific requirements are communicated. All verbal requests must be followed up with an ICE request form printed directly to the transfusion laboratory printer, P062747; or a hand written form can be sent in the POD systemDo not over order, see table belowTYPE ORDER TIMETIME DELIVEREDSTANDARD PLTSUP TO 16:15Mon-Fri19:0016:16 – 07:00 Mon-Thurs11:00 16:16 Friday - 07:00 Mon(weekend)11:00 MondayHLA PLTS24 hours notice minimumUP TO 11:00 Mon – Thurs11:00 The following day11:01 Thurs- 16:30 Thurs19:00 Friday16:31Thurs- 11:00 Sun11:00 MondayWASHED PLTS48 hours notice48 hours noticeOn the first Routine delivery after 48 hours 11:00 or 19:00If required urgently, random platelets may be issued on the advice of a Haematologist (Laboratory staff will advise accordingly)If platelets are required outside these times CONSULTANT approval is required. This will only be for instances of Emergency where random stock platelets are not availableFollowing prophylactic platelet transfusions, always review the patients’ response to each bag before ordering more.Which ABO group will be supplied?Usually the same as the patients’ ABO group but you may be supplied with another group that will be compatible. This will depend upon platelet stock availability, especially if patient has specific requirements e.g. HLA, irradiated. NB. Compatibility of ABO groups differ in platelet and plasma components from red cellsRh D group:Rh D negative components will be given, when possible, and particularly to females who are Rh D negative or unknown and <55 years oldIf Rh D positive platelets are given to RhD negative women who are <55 years old then prophylactic Anti D should be administered – 250 units for every 5 adult doses of platelets in a 6 week period.Anti D is not required for Rh D negative/unknown males, or women ≥ 55 yearsResponse to platelet transfusionA repeat FBC must be taken after platelet transfusion in bleeding patients or before critical procedures to ensure there has been an increment.For prophylactic indications for platelets – you can use the next morning’s FBC if an inpatient.The 10 minute or 1-hour post platelet transfusion FBC can be used for day cases.USE OF FRESH FROZEN PLASMA (FFP) AND CRYOPRECIPITATEPlease note patients born after 1st January 1996 or unknown, and/or plasma exchange will be issued OctaplasLG? in place of FFP and Methylene Blue Cryoprecipitate as per national guidance The approval of a Haematologist for use of these components is required, except DCCQ and NICU.Issue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automatic.FFP is given primarily for two indications: To prevent bleeding (prophylaxis) To stop bleeding (therapeutic) Prophylactic transfusions are mainly used prior to surgery or invasive procedures. Many possible indications in patients without major bleeding are not substantiated by robust trial data (British Society of Haematology Guidelines, 2018).FFP is not to be given for reversal of Warfarin. Use Prothrombin Complex Concentrate (Octaplex?)Background - CoagulopathyCoagulopathy occurs in many medical and surgical illnesses, for example:Massive blood lossDisseminated Intravascular Coagulopathy (DIC)Requirements for issuing FFP and Cryoprecipitate Abnormal coagulation results and haemorrhageConsider the need for fibrinogen estimation in significant haemorrhage cases and where there may be DIC such as meningococcal septicaemiaRisk of haemorrhage and abnormal coagulation - such as before a procedure or to prevent further bleeding when coagulopathy cannot be fully reversed Examples include preventing further bleeding in liver disease patients with a recent intracranial bleedRepeat coagulation screen is indicated to see if the FFP has corrected the abnormal coagulation before starting invasive proceduresSee Indication codes Appendix 1Remember patients born after 1st January 1996 or unknown, and/or plasma exchange will be issued OctaplasLG? in place of FFP and Methylene Blue Cryoprecipitate as per national guidance The patient MUST have a known blood group on the laboratory system second sample rule applies as in red cells.Group AB Plasma will be issued in an emergency where no sample is availableDose 15ml /kg.Cryoprecipitate is issued with the approval of a Consultant HaematologistCOMMON – acquired hypofibrinogenaemia as seen in DIC, massive bleedingwhere the patient is bleedingafter use of FFP / plateletsVery RARE – inherited dysfibrinogenaemiaWhere the patient is bleedingBefore a procedure likely to cause a bleedIssue within the ‘Massive Transfusion (Haemorrhage) Guideline’ will be automatic.See Indication codes Appendix 1TRAINING REQUIREMENTSTransfusion training forms part of the Trust’s Essential Skills and Training Requirements. This is included in the mandatory Corporate Induction and Essential Skills UpdatesStaff must attend a classroom based, face-to-face ‘Blood Awareness Update’ every two yearsThis training is recorded on the individuals ESR (Electronic Staff Record) and is indicated on the Matrix when training is dueThe Learning and Development Team provide compliance updates to managers in clinical areasCompliance is further monitored through the CSC performance reviews with the Executive TeamThere is a Trust Competency for preparing and administering blood or blood components. Staff must be assessed by a level three assessor and have this signed to a minimum of level twoStaff do not need to be reassessed if practicing transfusion within a one year periodREFERENCES AND ASSOCIATED DOCUMENTATIONAnnual SHOT Report Blood Safety and Quality Regulations (BSQR) 2005 NICE Guidelines (NG24) November 2016BSH GuidelinesPHT Speciality Guidelines and Policies, WRTS Blood Administration: Adults on Haemodialysis/HaemofiltrationPHT Consent to Examination and Treatment Policy PHT Blood Sampling Policy (Adults)PHT Policy on Patients Who Wish to Decline TransfusionsPHT Neonatal / Paediatric GuidelinesPHT Massive Transfusion (Haemorrhage) GuidelinePHT Patient Identification PolicyPHT Drug Therapy Guideline No 161.00 Issued: 25.01.13 Use of OctaplasLG?British Committee for Standards in Haematology (2012). Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. British Journal of Haematology, 160, 445-46British Committee for Standards in Haematology (2012). Guideline on the administration of Blood ComponentsBritish Committee for Standards in Haematology (2015). A practical guideline for the haematologicalmanagement of major haemorrhage. British Journal of Haematology, 170, 788-803British Committee for Standards in Haematology (2016). Draft guidelines for the use of platelettransfusionsBritish Society of Gastroenterology (2015). UK guidelines on the management of variceal haemorrhage in cirrhotic patients. GUT, 0, 1-25 British Society of Gastroenterology, Clinical Services, Care Bundles. British Society of Gastroenterology & British Association for the study of the Liver Decompensated Cirrhosis Care Bundle – First 24 Hours..ukBritish Society of Haematology (2018) Guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding Society of Anaesthesiology Guidelines (2013). Management of severe perioperative bleedingRoyal College of Obstetricians & Gynaecologists (2015). Blood Transfusion in Obstetrics. Green-top Guideline No 47National Blood Transfusion Committee Indication Codes – An Audit Tool (June 2016) EQUALITY IMPACT STATEMENTPortsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.This policy has been assessed accordinglyOur values?are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:Working together….for Patientswith Compassionas One TeamAlways ImprovingThis policy should be read and implemented with the Trust Values in mind at all times.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTSMinimum requirement to be monitoredLeadToolFrequency of Report of ComplianceReporting arrangementsLead(s) for acting on Recommendations100% transfusion samples taken and labelled as per policyPhlebotomy TrainerSpot checksAnnuallyPolicy audit report to:HTCHTC Chair and TPRequests for transfusion to be made appropriatelyTransfusion Lab ManagerAuditAnnuallyPolicy audit report to:HTCTLMPolicy for administration of all transfusions is followedTPAuditQuarterlyPolicy audit report to:HTCTP / TPE100% of staff involved in the process are competentTPESR records held by L&D and signed competency2 yearlyPolicy audit report to:HTCTP/TPEThis document will be monitored to ensure it is effective and to assure complianceAPPENDIX 1: Indication Codes for TransfusionINDICATION CODES FOR TRANSFUSION The indications for transfusion provided below are taken from national guidelines for the use of blood components in adults (see references). Amalgamation into this summary document aims to act as a prompt for clinicians to facilitate appropriate use and to enable robust documentation of indications.Each indication has been assigned a number, to permit reproducible coding, when requesting blood or for documentation purposes. Specific details regarding the patient’s diagnosis and any relevant procedures to be undertaken should also be provided at request either on a written request form, electronic blood order or by telephone when the request is urgent.These are current guidelines and may change depending on new evidence. R5b, R7a and R7b are specific to PHTRed cell concentratesDose - in the absence of active bleeding, use the minimum number of units required to achieve a target Hb. Consider the size of the patient; assume an increment of 10g/L per unit for an average 70 kg adult. R1Acute Bleeding: Acute blood loss with haemodynamic instability. After normovolaemia has been achieved/maintained, frequent measurement of Hb (including near patient testing) should be used to guide the use of red cell transfusion – see suggested thresholds below.R2Hb ≤ 70g/L stable patient: Acute anaemia. Use an Hb threshold of 70g/L and a target Hb of 70-90g/L to guide red cell transfusion. Follow local/specific protocols for indications such as post cardiac surgery, traumatic brain injury, and acute cerebral ischaemia.R3Hb ≤ 80g/L if cardiovascular disease: Use an Hb threshold of 80g/L and a target Hb of 80-100g/L.R4Chronic transfusion dependent anaemia: Transfuse to maintain an Hb which prevents symptoms. Suggest an Hb threshold of 80g/L initially and adjust as required. Haemoglobinopathy patients require individualised Hb thresholds depending on age and diagnosis.R5aRadiotherapy maintain Hb > 110g/L: There is limited evidence for maintaining an Hb of 110g/L in patients receiving radiotherapy for cervical and possibly other tumours.R5bRadiotherapy Squamous Cell Carcinoma (Head & Neck/Gynae only) Hb > 115g/L (PHT) R6Exchange transfusionR7aOrthogeriatric # NOF Hb ≤ 90g/L (PHT)R7bOrthogeriatric # NOF Hb ≤ 100g/L if cardiovascular disease (PHT)Platelet concentratesDose – for prophylaxis, do not routinely transfuse more than 1 adult therapeutic dose. Prior to invasive procedure or to treat bleeding, consider the size of the patient, previous increments and the target count.Prophylactic platelet transfusionP1Plt <10 x 10*9/L reversible bone marrow failure. Not indicated in chronic bone marrow failureP2Plt 10 - 20 x 10*9/L sepsis / haemostatic abnormalityPrior to invasive procedure or surgeryP3To prevent bleeding associated with invasive procedures. Transfuse platelets if:-? P3aPlt <20 x 10*9/L central venous line? P3bPlt <40 x 10*9/L pre lumbar puncture/spinal anaesthesia? P3cPlt <50 x 10*9/L pre liver biopsy / major surgery? P3dPlt <80 x 10*9/L epidural anaesthesia? P3ePlt <100 x 10*9/L pre critical site surgery eg CNSTransfusion prior to bone marrow biopsy is not requiredP4Therapeutic use to treat bleeding (WHO bleeding grade 2 or above, see appendix ix, page 38? P4aMajor haemorrhage Plt <50 x 10*9/L? P4bCritical site bleeding eg CNS / traumatic brain injury Plt < 100 x 10*9/L? P4cClinically significant bleeding Plt < 30 x 10*9/LP5Specific clinical conditions? P5aDisseminated Intravascular Coagulation (DIC) pre procedure or if bleeding? P5bPrimary immune thrombocytopenia (emergency treatment pre-procedure/severe bleeding)P6 Platelet dysfunction? P6a Consider if critical bleeding on anti-platelet medication? P6b Inherited platelet disorders directed by specialist in haemostasisFresh frozen plasmaDose - 15 ml/kg body weight, often equivalent to 4 units in adults.F1 Major haemorrhage: Early infusion of FFP is recommended in a ratio of 1 unit FFP: to 1 unit red cells for trauma and at least 1 unit FFP: 2 unit’s red cells in other major haemorrhage settings. Once bleeding is under control, FFP use should be guided by timely tests for coagulation as indicated below.F2PT Ratio/INR > 1.5 with bleeding: Clinically significant bleeding without major haemorrhage. FFP required if coagulopathy. Aim for a PT and APTT ratio of < 1.5.F3 PT Ratio INR >1.5 and pre-procedure: Prophylactic use when coagulation results are abnormal e.g. Disseminated Intravascular Coagulation (DIC) and invasive procedure is planned with risk of clinically significant bleeding.F4Liver disease with PT Ratio/INR > 2 and pre-procedure: FFP should not be routinely administered to non-bleeding patients or before invasive procedures when the PT ratio/INR is ≤ 2.F5TTP/plasma exchangeF6Replacement of single coagulation factorProthrombin complex concentrateDose should be determined by the situation and INR. Local guidelines should be followed.PCC1 Emergency reversal of vitamin K antagonists (VKA) for severe bleeding or head injury with suspected intracerebral haemorrhage.PCC2Emergency reversal of VKA pre emergency surgeryCryoprecipitateDose – 2 pooled units, equivalent to 10 individual units, will increase fibrinogen by approximately 1g/L.Cryoprecipitate is usually used with FFP unless there is an isolated deficiency of fibrinogen.C1Clinically significant bleeding and fibrinogen <1.5g/L (<2g/L in obstetric bleeding)C2Fibrinogen <1g/L and pre procedureC3Bleeding associated with thrombolytic therapyC4Inherited hypofibrinogenaemia, fibrinogen concentrate not availableAPPENDIX 2: Blood Transfusion, Size Matters!17621254000500Version 3 – October 20161247774102235(SHOT Report, 2016)00(SHOT Report, 2016)38766756608445Version 3 – October 201600Version 3 – October 2016159067565532000APPENDIX 3: Consent for TransfusionAvailable to order from Medical Illustration ref: 16-0765APPENDIX 4: Written InstructionWritten Instruction: Side One12382516002000Written Instruction: Side Two02857500APPENDIX ivAPPENDIX 5: Blood Component Specific RequirementsBlood Component Specific RequirementsTransfusion associated graft versus host disease (TA-GvHD) is a rare but serious complication of blood transfusion caused by lymphocytes which may be present in donor blood. Mature donor T cells recognise alloantigen’s in the recipient and become activated leading to cytokine production and lymphocyte proliferation. Inflammation and tissue damage follow.The risk associated with an individual transfusion depends on the number and viability of contaminating lymphocytes, the susceptibility of the patient’s immune system to their engraftment and the degree of immunological (HLA) disparity between donor and patient. Gamma-irradiation of blood prevents lymphocytes dividing and causing harm.The Clinician must notify the Transfusion Laboratory that the patient has specific requirements via letter on EPRO and indicate this on any transfusion request form. Indications for Irradiated blood components:Patients receiving transfusions from first or second-degree relatives, even if patient is immunocompetentAll HLA selected platelets are irradiated Patients with inherited deficiencies in immunity which compromises T lymphocyte function (except chronic mucotaneous candidiasis)Hodgkin’s disease patientsPatients who have received treatment with purine analogues e.g. fludarabine, cladrabine, clofaribine, bendamustine and pentostatinPatients who have received treatment with alemtuzumab and ATGPatients who have had an allogeneic haematopoietic stem cell transplant until GVHD prophylaxis is completed and / or lymphocyte count greater than 1 x 109/lPatients undergoing autologous haematopoietic stem cell transplant. Irradiation should be commenced 7 days prior to HPC harvesting to prevent collection of viable allogeneic lymphocytes, which cause TA-GvHD after reinfusion. Irradiated components are continued for 3 months or 6 months if the patient received total body irradiationPatients not at riskSolid organ transplant – TA-GvHD has been documented in recipients of liver, lung and kidney transplants but this is ordinarily associated with the transfer of donor lymphoid tissue with the graftHIVSolid tumoursNon-Hodgkin’s lymphoma – currently under review by BSHIt is essential that ALL patients requiring irradiated blood components are informed of this fact, provided a card and an information leaflet – Information for patients needing irradiated blood, supplies available. See below for example of card. Patients should be advised to carry this with them at all times16440156667500Cytomegalovirus (CMV) negative components:CMV is widespread in the population but infections are rarely problematic in the immunocompetent population. However, it has been associated with serious morbidity in vulnerable patients. The risk of transmission via transfusion has been reduced due to the process of leucocyte depletion. However, there are still occasions where it is recommended to use CMV negative components.Indications for CMV negative components:Patients presenting with a haematological malignancy in which haematopoietic stem cell transplant is a possible future therapeutic option pending the result of their CMV antibody statusPregnant women who are CMV negative or in whom their status is unknownPatients who have had an autologous haematopoietic stem cell transplant within the previous 6 monthsPatients who have had an allogeneic haematopoietic stem cell transplantPatients who are HIV positive and whom are CMV negativePatients who have received treatment with alemtuzumabAPPENDIX 6: Emergency Blood IssueEmergency Blood IssueCall 4444When a massive haemorrhage is called blood and blood components will be issued according to the ‘Massive Transfusion (Haemorrhage) Guideline’ (available on the Trust Intranet) as belowRBCsFFPPlatsCryoPack A441------Pack B4412O Pos blood will be issued for male patients (over 18 yrs) and older females > 55yrs (over potential childbearing years).APPENDIX 7: Acute Transfusion Reactions (ATR)APPENDIX 8: Common Complications Associated with Transfusion of a Blood ComponentCommon Complications Associated with Transfusion of a Blood ComponentProblemLikely CauseTiming of EventSeverityManagement and PreventionAcute EventIntravascular HaemolysisMajor ABO incompatibilityAlmost immediately following start of transfusionPotentially fatal10% MortalityCheck for DIC and renal failureMaintain BP and renal perfusionContact: On-call Haematologist, T P, Transfusion LaboratoryInitiate RED Safety Learning Event report (Datix)TACO (Transfusion Associated Circulatory Overload)Rapidly infused, large volume infusions or high TACO risk patientsOccurs usually within 2 - 6 hours of transfusionPotentially fatalAccurate assessment of patients at risk of TACOCareful attention to fluid balanceConsider appropriateness of transfusionConsider rate of transfusion and diuretic coverInitiate AMBER Safety Learning Event report (Datix)TRALI (Transfusion Related Acute Lung Injury)Leucocyte Antibodies in donor bloodDuring or within 6 hours of transfusion – RARE but can be confused with ARDS (Acute Respiratory Distress Syndrome)Potentially fatalManage as for ARDS refer to Critical Care TeamChest X-Ray – shows bilateral pulmonary infiltratesInitiate AMBER Safety Learning Event report (Datix)TAD (Transfusion Associated Dyspnoea)Transfusion of donor blood and patient co-morbiditiesRespiratory distress within 24 hours of transfusion and no other associated causePotentially fatalAssess respiratory distressCXROxygen saturations and ABG’sInitiate Safety Learning Event report (Datix) grade appropriatelyAnaphylaxisIgA Antibodies in donor or recipient ImmediatePotentially fatalMaintain ABC’s and follow Anaphylaxis PolicyInitiate Safety Learning Event report (Datix) grade appropriatelySeptic ShockBacterial contaminationDuring transfusionPotentially fatalManage septicemiaInitiate Safety Learning Event report (Datix) grade appropriatelyFebrile, Non-haemolyticAnti-leucocyte antibodiesUp to several hours post transfusionUnpleasant but not usually life threateningTreat with Anti-pyretic (e.g. Paracetamol 1g)Initiate Safety Learning Event report (Datix) grade appropriatelyUrticariaIgE Antibodies in donor bloodDuring transfusionUnpleasant but not usually life threateningTreat or prevent with Antihistamine (Oral or IV)Initiate Safety Learning Event report (Datix)grade appropriatelyDelayed EventDelayed haemolytic reactionIgG Antibodies to donor blood2 – 26 days post transfusionNot usually life threateningPoor response to transfusionJaundiceSend samples for investigationReview transfusion needsTA-GvHD (Transfusion Associated Graft Versus Host Disease)Donor lymphocytesExtremely rare up to 30 days following transfusionUsually fatalNone seen in the last 10 years following leucocyte depletionIrradiated blood to ‘at risk’ groupsPost Transfusion Purpura (PTP)Recipient antibodies against HPA system5 – 12 days post transfusionRare but treatableContact Bloodbank to arrange patient investigation at platelet laboratory Post Transfusion Viral InfectionInfected donor bloodPost transfusionRare Depends on virusSeek specialist medical adviceIron overloadMulti-transfused patientsOccurs either with single episode of multi-units or long term transfusion therapiesRare but treatable if diagnosedUse iron chelation therapy or venesectionMonitor LFT’s and cardiac enzymesConsider cardiac scansAPPENDIX 9: Modified WHO Bleeding ScoreModified World Health Organization Bleeding Score GradeType of Bleeding1aVisual impairment is defined as a field deficit, and patients with suspected visual impairment require an ophthalmological consultation1Petechiae/purpura that is localized to 1 or 2 dependent sites, or is sparse/non-confluentOropharyngeal bleeding, epistaxis<30 min duration2Melaena, haematemesis, haemoptysis, fresh blood in stool, musculoskeletal bleeding, or soft tissue bleeding not requiring red cell transfusion within 24?h of onset and without haemodynamic instabilityProfuse epistaxis or oropharyngeal bleeding >30?minSymptomatic oral blood blisters, i.e. bleeding or causing major discomfortMultiple bruises, each >2?cm or any one >10?cmPetechiae/purpura that is diffuseVisible blood in urineAbnormal bleeding from invasive or procedure sitesUnexpected vaginal bleeding saturating more than 2 pads with blood in a 24-h periodBleeding in cavity fluids evident macroscopicallyRetinal haemorrhage without visual impairment3Bleeding requiring red cell transfusion specifically for support of bleeding within 24?h of onset and without haemodynamic instabilityBleeding in body cavity fluids grossly visibleCerebral bleeding noted on computed tomography (CT) without neurological signs and symptoms4Debilitating bleeding including retinal bleeding and visual impairmentNon-fatal cerebral bleeding with neurological signs and symptomsBleeding associated with haemodynamic instability (hypotension, >30?mmHg change in systolic or diastolic blood pressure)Fatal bleeding from any sourceEQUALITY IMPACT SCREENING TOOLTo be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.Stage 1 - Screening Title of Procedural Document: Transfusion Policy (Adult)Date of Assessment06/07/2018Responsible DepartmentHTCName of person completing assessmentKay HeronJob TitleTransfusion PractitionerDoes the policy/function affect one group less or more favourably than another on the basis of :Yes/NoCommentsAgeNoDisabilityNoGender reassignmentNoPregnancy and MaternityNoRaceNoSexNoReligion or BeliefNoSexual OrientationNoMarriage and Civil PartnershipNoIf the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2More Information can be found be following the link below.uk/ukpga/2010/15/contents ................
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