1. To safely administer blood components and plasma derived pharmaceuticals to patients as required.
2. To be aware of and identify patients that may require modified blood components i.e. irradiated or CMV negative components.
3. To be aware of the principles of Patient Blood Management i.e endeavour to optimise the patient’s own blood volume, minimise blood loss, and optimise the patient’s physiological tolerance of anaemia.

1.To safely administer blood components and plasma derived products to patients as required.

2. To provide special blood components to those patients who require them:

Key Points

Refer to each section for relevant definitions.

RED BLOOD CELLS

INDICATIONS

For the treatment of clinically significant anaemia with a symptomatic deficit of oxygen carrying capacity, and for the replacement of traumatic or surgical blood loss.

DEFINITIONS

• Allogeneic Blood: Blood donated from a blood donor.

• Red Cells Leucocyte Depleted:  Red cells are obtained after centrifuging whole blood then resuspended in an additive solution and filtered to remove most leucocytes.

• Red Cells Pedipaks: A unit of red cells is divided into four packs of equal volume for the purpose of reducing donor exposure for small paediatric transfusions.

• Red Cells Washed Leucocyte Depleted:  Red cells are washed with normal saline to remove the majority of plasma proteins.  Indicated for patients who have IgA deficiency with antibodies against IgA.

ISSUES TO CONSIDER

When prescribing red blood cells, consideration should be given to the risks and benefits of the transfusion in relation to the patients haemoglobin and clinical signs and symptoms of anaemia.

Blood Warmers (Refer to CPP0440: Blood and Fluid Warmers)

ADMINISTRATION TIME FRAME

• Transfusion of blood components must commence within 30 mins of issue from the transfusion laboratory and MUST be completed within 4 hours of being connected to the IV line.

• If there is a delay in commencement the red blood cells MUST be returned to pathology within 30 minutes of removal.

• If > 30 minutes has elapsed and there is an intention to transfuse, the bag can remain on the ward but must be completed within 4 hours and 30 mins of initially leaving the refrigerator. If it has been spiked, it must be completed within 4 hours of being spiked. If any blood remains in the bag after these time frames it must be discarded and documented in the patient record.

TRANSFUSION OF RED CELLS AT SUBACUTE SITE

• Single units of blood for use at Subacute (Gandarra, Inpatient Complex Care Unit and Rehabilitation Unit) are packed by pathology staff and transported via taxi.  The time of packing will be indicated on the shipper.

• The blood should still be commenced within 30 minutes of removal from fridge; therefore, it is very important to have patient ready for transfusion prior to requesting the blood to be sent.

• Blood transfusions should only occur on weekdays between 0800hrs and be completed by 1700hrs.

• The medical officer should stay in the vicinity for the first 15 minutes of each bag of blood commencing and then available by phone if needing to be called during the procedure.

 SPECIAL PRODUCT REQUIREMENTS

•  Consideration should be given to whether the patient requires special blood components such as CMV negative or irradiated components.

•  All red blood cells and platelets are leucocyte depleted at the Red Cross Blood Service prior to distribution to hospitals.  There is no need for the addition of a bedside leucocyte depletion filter.  However, all fresh blood products must be administered via a 170 200-micron blood filter.

PLATELETS

INDICATIONS

• Platelet transfusions are dependent on the aetiology of the disease.

• Prevention and treatment of bleeding in patients with thrombocytopaenia.

• Prophylactic use in bone marrow failure when the platelet count is:

  <10 x 10/L without risk factors     <20 x 10/L in the presence of risk factors such as fever, antibiotics and sepsis.

• To maintain the platelet count at >50 x 10/L in patients undergoing surgery or invasive procedures.

• During massive transfusion when the platelet count is <50 x 10/L.

• Management of diffuse microvascular bleeding when the platelet count is <100 x 10/L.

• Management of bleeding in patients receiving anti-platelet medication.

DEFINITIONS

• Pooled Platelets: Consists of 4 individual platelet units derived from whole blood donations from ABO identical donors and resuspended in a nutrient additive solution.  Volume approximately 200ml will be indicated on the platelet label.

• Single Donor Platelets: are collected by apheresis and suspended in plasma or nutrient additive solution. Volume approximately 200ml will be indicated on the platelet label. Two therapeutic doses may be collected via apheresis. These will be labeled 'Platelets 1 of 2'; Platelets 2 of 2'

• Paediatric Platelets: single donor platelets are separated into 4 packs of equal volume for the purpose of reducing donor exposure for small paediatric transfusions and to minimise wastage.  Volume approximately 50ml each.

ISSUES TO CONSIDER

• Platelets can be stored for seven days at 20 - 24C. Platelets must be agitated gently and continuously on a platelet rocker during storage in a single layer. Because they are stored at room temperature, the risk of bacterial contamination is high.

• Platelets must not be refrigerated.

• Available in groups O, A and B; and Rh(D) positive and negative groups.

• Platelets received from Australian Red Cross Lifeblood are irradiated and leucocyte depleted and therefore do not require further leucocyte filtration at the bedside as this would result in a further reduction of platelets transfused.

• It is nursing staff responsibility to check that the label on the platelet pack states that they are irradiated and leucocyte depleted.

• One of the benefits of pre-storage leucodepleted platelets is a reduction in febrile non-haemolytic transfusion reactions due to the early removal of the majority of cytokine-generating white cells.  For this reason, fevers associated with the transfusion of leucodepleted platelets should be carefully assessed to exclude complications such as bacterial contamination.

• One bag of platelets would be expected to raise the platelet count in a 70kg adult by 20-40 x 10/L

• Transfuse as fast as the patient can tolerate through a standard blood giving set incorporating a 170 -200 micron filter.  Each bag must be completed within 4 hours.

• Platelets are normally administered by gravity but can be delivered via the Alaris infusion pump using the appropriate giving set at a maximum rate of 999ml / hour (useful when PICC lines are insitu).

FRESH FROZEN PLASMA (FFP)

INDICATIONS

FFP is given to correct coagulation issues:

 FFP is not recommended or appropriate in these cases:

• Hypovolaemia alone

• Plasma exchange procedure (TTP excepted)

• Treatment of immunodeficiency states

• As a source of immunoglobulins

• Where a suitable virus inactivated specific clotting factor concentrate is available

• In a patient with intolerance to plasma proteins

DEFINITIONS

• Fresh Frozen Plasma: FFP is human plasma separated from donated whole blood or collected via apheresis and frozen to minus 25C. It contains all coagulation factors including labile factors V and VIII.  Volume per bag is approximately 300mL. Two to three therapeutic doses may be collected via apheresis. These will be labeled 'FFP 1 of 2'; 'FFP 2 of 2'; 'FFP 1 of 3' etc

• Extended Life Plasma (ELP): is thawed Fresh Frozen Plasma (FFP) which can be stored between 2 to 6 Celsius for up to 5 days from the time of thawing.

• Paediatric Fresh Frozen Plasma: packs are prepared from a single donation and then divided into four packs of equal volume (approx 70ml) for the purpose of reducing donor exposure for all small paediatric transfusions, and to reduce product wastage.

• Cryo-Depleted Plasma: CDP is the supernatant remaining after cryoprecipitate has been removed from FFP.  It contains most clotting factors in similar amounts to FFP but is deficient in Factor VIII, von Willebrand Factor, Factor XIII and fibronectin.  It is recommended for plasma exchange in TTP.

ISSUES TO CONSIDER

• The recommended dose of FFP is 10-15ml/kg.

• For maximum clotting factors, FFP should be transfused within 6 hours of thawing, but may be stored within the blood bank refrigerator for up to 24 hours.

• If FFP is thawed and not used it may be relabelled as extended life plasma (ELP) with a shelf-life of up to 5 days after initial thawing, if stored at 2-6C. This has the benefit of being available when required and a potential reduction in wastage of thawed plasma that was previously only valid for 24 hours. ELP may not be suitable for all patient groups, especially neonates and freshly thawed products should be used for this patient population. 

• FFP should be administered immediately upon arrival to the ward / department.

• Transfuse as fast as the patient can tolerate through a standard blood giving set incorporating a 170 -200 micron filter.  Each unit must be completed within 4 hours.  Carefully monitor the patient for fluid overload.

• FFP is available in all ABO groups and blood group-compatible plasma should be used. It is issued on the patients ABO group only Rh status is NOT relevant.

CRYOPRECIPITATE

INDICATIONS

For the treatment of fibrinogen deficiency or dysfibrinogenaemia when there is clinical bleeding, DIC, trauma or any invasive procedure where the fibrinogen level is <1.0g/L.

DEFINITIONS

• Cryoprecipitate: prepared from thawing FFP and recovering the cold-insoluble precipitate which is then refrozen.  It contains most of Factor VIII, Fibrinogen, Factor XIII, von Willebrands Factor and fibronectin.

• Cryoprecipitate Apheresis:  prepared from thawing apheresis FFP and recovering the precipitate.  One unit of cryoprecipitate apheresis is approximately equivalent to two units of whole blood derived cryoprecipitate.

ISSUES TO CONSIDER

• It takes approximately fifteen minutes to thaw at 37C in a water bath and once thawed it MUST be used within six hours.

• Thawed cryoprecipitate should be maintained at 20-24C until transfused.

• Transfuse as fast as the patient can tolerate through a standard blood giving set incorporating a 170 -200 micron filter.  Each bag must be completed within 4 hours.

• A common dose for fibrinogen replacement is 1 1.5 bags per 10kg patient body weight.

• Each bag of cryoprecipitate is prepared from one donor and has a volume of approximately 10 - 40 mls.

• Although compatibility tests are not necessary before transfusion it is preferable that the cryo is group compatible with the patients red cells. However, ABO incompatible cryo can be used with caution. Rh status is NOT relevant

ALBUMIN

DESCRIPTION

Albumin is a protein solution made from pooled human plasma.  It is stored at room temperature and is available as:

Albumin 4%:

• Albumex 4: 2 g in 50 mL, 10 g in 250 mL, 20 g in 500 mL

Albumin 20%:

• AlbuRex 20 AU: 10 g in 50 mL, 20 g in 100 mL

Albumin 4% is iso-oncotic with human serum. When infused into adequately hydrated patients its effect is to expand the circulating blood volume by an amount approximately equal to the volume of Albumin 4% infused.

The colloid osmotic effect of Albumin 20 % is approximately 4 times that of plasma.

 INDICATIONS

• Shock associated with significant hypoalbuminaemia (albumin concentration less than 25 g/L)

• Cardiothoracic surgery pump priming in patients with poor LVF and other complicating factors such as long bypass time, repeat surgery or anaemia

• Therapeutic plasmapheresis particularly when the volume exceeds 20 mL/kg body weight

• Patients with extensive burns

• Paracentesis of ascites in patients with cirrhosis or when the volume drained exceeds 6 litres

• Haemodialysis - maybe used to assist rapid removal of excess extravascular fluid and to maintain perfusion pressure

 ISSUES TO CONSIDER

• Albumin is dispensed from pharmacy and prescribed on the Blood product prescription form MR/683.02. Consent must be obtained on the Blood product consent form MR/683.02

• Imprest stocks are available in Emergency, ICU and Theatre.  Each time a bottle is used from the imprest stock, patient details must be recorded in the traceability register (DD book in ICU).

• Each bottle has a removable batch number that must be removed and placed on "blood product" section on the Blood product prescription form MR/683.02

• Albumin can be administered through a standard vented giving set via an infusion pump.

• Albumin does not contain an antimicrobial preservative.  It must therefore, be used immediately after spiking the bottle and completed within 4 hours

• Do not mix with other solutions

• Albumin 4% usual rate of administration is between 2 and 4 hours.  Rapid infusion may lead to circulatory overload.

• AlbuRex 20 AU contains 140 mmol/L.  Use with care in patients requiring sodium restriction. 

• Rate should not exceed 2 mL/min for use in hypoproteinaemia in the acutely ill patient.

• To avoid circulatory overload the patient must be monitored throughout the infusion.  Minimum observations of TPR, BP, and Oxygen saturation are recorded prior to infusion commencing, hourly and at end of infusion.

• Albumin may vary in colour from a pale straw to amber to a greenish tint.  If the product appears to be turbid by transmitted light, it must not be used and the bottle returned via pharmacy to Australian Red Cross Blood Lifeblood. 

IRRADIATED BLOOD COMPONENTS

INDICATIONS

Blood components that contain viable lymphocytes may be irradiated to prevent the proliferation of T-lymphocytes, which is the immediate cause of transfusion-associated graft versus host disease (TA-GVHD).

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare, but almost universally fatal, iatrogenic complication of transfusion.  The inherent risk associated with an individual transfusion depends on the interplay of several factors, including the number and viability of contaminating lymphocytes in the transfused cellular component, the susceptibility of the patient's immune system to the engraftment of donor lymphocytes, and the degree of immunological (human leucocyte antigen, HLA) homology between the donor and the recipient. 

Gamma irradiation to inactivate viable T lymphocytes contained within the blood components remains the mainstay in prevention of TA-GVHD.

Irradiated blood components are given to avoid development of transfusion associated graft versus host disease (Ta-GVHD).

Patients who have been identified as requiring irradiated blood will have an alert placed on BOSSNet. Pathology will list the requirement in their IT system and the patient shall be informed and given an information card. This is overseen by the CNC Blood Management / Transfusion.

1. Definite indications: These are indications where there is strong evidence to support the requirement for use of irradiated blood components or where there is clear consensus on the requirement within published guidelines

2. Possible indications: This includes settings where case reports have been published but where no controlled studies are available.

3. No indication: No cases have been reported or insufficient evidence to mandate routine irradiation.

** Although not listed as definite indications, consideration should be given to transfusing patients with these condition with irradiated red blood cells. Irradiated blood will not routinely be issued to patients with other conditions and should not be requested.

The effect of irradiation on efficacy and safety of different components has been extensively evaluated, and while not definitely clinically significant, physiological changes have been demonstrated in cellular components. 

Gamma irradiation increases the supernatant potassium level.  Extracellular potassium levels increase more rapidly during storage in irradiated compared with non-irradiated red cells.  Rapid infusion of potassium can have deleterious cardiac effects.  Generally, with top-up transfusions infused at usual rates, the potassium load is of little clinical significance.  However, it is of concern in infants and in large volume transfusions such as exchange transfusion, intrauterine transfusion and rapid massive transfusion in resuscitation settings.  Therefore, in considering the clinical significance, both the speed and volume of the transfusion, as well as the age of the blood, must be taken into account.  

DEFINITIONS

Irradiated Blood Components: A suitable dose of gamma irradiation is given to blood components (red cell products, platelet concentrates) to inactivate lymphocytes.

• Red cells can be irradiated up to 14 days following collection, and then expire 14 days after irradiation. 

• Platelets can be irradiated at any stage of their seven day life.  

Transfusion Associated Graft versus Host Disease (TA-GVHD): occurs when viable T-lymphocytes contained in cellular blood components (red cell products, platelets and granulocytes) are not rejected by the recipients immune system, they then engraft and attack recipient host tissues.  This rare condition is fatal.

 ISSUES TO CONSIDER        

• Gamma irradiation of red cells increases the rate of efflux of intracellular potassium.  Therefore the speed and volume of the transfusion and the age of the blood must be taken into account when transfusing irradiated components. 

• Where the patient is at particular risk of hyperkalaemia, it is recommended that red cells be transfused within 24 hours of irradiation.

• Neonates should only have blood products that have been irradiated within the previous 24 hours.

CMV NEGATIVE BLOOD COMPONENTS

 INDICATIONS

 To prevent transmission of cytomegalovirus (CMV) to CMV seronegative recipients who have the potential to develop clinically significant disease.

Suggested recipients of CMV negative blood components:

• CMV seronegative recipients or potential recipients of allogenic or autologous stem cell, bone marrow or solid organ transplants

• CMV seronegative recipients of highly immunosuppressive chemotherapy e.g. leukaemia, lymphoma

• Recipients of intrauterine red cell transfusions

• Premature (<1500g) or immunocompromised neonates

• CMV negative pregnant women who require transfusion

• Severely immunocompromised patients

 DEFINITIONS

• Cytomegalovirus (CMV): CMV is a latent virus transmitted via leucocytes.  Immunocompromised and bone marrow transplant patients are at significant risk of systemic and life-threatening illness if exposed to CMV.

• CMV Negative Blood Components: Blood components that have been tested and are seronegative for the cytomegalovirus.

 ISSUES TO CONSIDER

• CMV negative components are not freely available.  If required they will need to be ordered 24 hours in advance. 

• Request for CMV negative components is made on the Dorevitch Blood Product Request Form at the time of crossmatch. 

• If not available, leucocyte depleted components are considered to offer a high level of safety in preventing CMV transmission.

A blood or blood product transfusion is contraindicated where a person with capacity refuses consent to that transfusion or where a person who does not have capacity has expressed their wishes not to have a transfusion in a written Advance Care Directive. Where the refusal of blood products is written and identified as an Instructional Advance Care Directive, this is a binding refusal under the law and should be applied as though the person was able to refuse the transfusion in person. Where the refusal of blood products is written and identified as a Values Advance Care Directive, a Medical Treatment Decision Maker is responsible for refusing consent.

 For COVID-19 blood/blood product administration procedures, refer to Appendix 6

    CONSENT FOR BLOOD TRANSFUSIONS and PLASMA DERIVED PRODUCTS

INDICATIONS

All patients (or person legally responsible for patient), except in cases of emergency transfusions, MUST:

• Have the risks and benefits of treatment with the blood product explained to them PRIOR to commencement of transfusion

• Have signed the Blood product consent form MR/683.02

• Have the Australian Red Cross Blood Transfusion information for patients explained to them

ISSUES TO CONSIDER

• Consent is to be obtained by the medical officer.

• Consent will be valid for the current admission for most patients.

• Extended consent for patients requiring on-going management with blood or blood products for a specific condition will remain valid indefinitely for that condition.  However, if the patient is admitted and requires transfusion treatment for a different condition, further consent will need to be obtained.

• Where it is anticipated that a patient may need transfusion of a blood component in an elective procedure, then the risks and benefits of the transfusion should be discussed with the patient at Preadmission Clinic and an information brochure should be given at this time.

• If blood transfusion is required during the peri-operative period, the general consent for procedure will cover this treatment.  However, if transfusion is required post this period i.e. the following day, a specific transfusion consent will be required.

• In the event of the patient being unable to give consent for whatever reason, then the Medical Treatment Decision Maker hierarchy must be followed.

THE CONSENT PROCESS

It is assumed that an adult person has capacity to consent to treatment. Where capacity is in question, there is a four step process to go through to determine if the person can consent (see Consent for Medical Treatment CPP0211). When consent for transfusion is obtained the process should involve a discussion with the patient that includes:

• the reasons for the proposed blood product transfusion

• the risks and benefits of the blood product

• the risks or consequences of not receiving the product

• the availability and appropriateness of any other blood management strategies

• an opportunity to ask questions

• use of a competent interpreter when the patient is not fluent in English

• use of written information or diagrams where appropriate

PATIENTS WHO REFUSE OF BLOOD PRODUCTS

A fully informed, competent adult patient is entitled to make the decision to accept medical treatment or refuse treatment.

Clinical staff are obliged to provide the patient with all the information necessary so the patient can make an informed decision, and then answer any questions the patient may have.

Clinical staff have an obligation to be satisfied that the patient is fully informed prior to the patient making the decision to refuse treatment.  If a patient is conscious and competent, staff should enquire as to what blood products the patient will accept or refuse.  If the patient is unconscious, or not competent to make an informed decision, staff are required to seek consent from the Medical Treatment Decision Maker. Where there is a binding Instructional Advance Care Directive stating that the person does not want any blood products, then this will function as though the person has refused treatment in person and must be complied with.

Clinical staff must accept and act on the patients informed decision irrespective of their personal beliefs and opinions.

If an adult patient (or person legally responsible for the patient) refuses a blood product transfusion, this must be recorded on an 'Advance care for adults' form - in Part 3: Instructional directive. The instructional directive is legally binding and if it lists transfusion, under no circumstances can transfusion of blood products proceed.

In the case of patients who are children, there are specific legal requirements and the Chief Medical Officer should be contacted for assistance.  In all cases involving children, the interests and welfare of the child is paramount.  Section 24 of the Human Tissue Act 1982 allows a medical practitioner to override a parents wishes refusing blood transfusion if it is the opinion of the treating doctor that the child is likely to die if transfusion is withheld.

JEHOVAH'S WITNESSES

Most Jehovahs Witnesses carry a Medical Directive that identifies who to contact in case of an emergency, any allergies, current medication or medical problems.  The Medical Directive clearly states the patients view on the non-administration of blood products. Note Jehovah's Witnesses will accept Non-blood volume expanders such as Gelofusine, Haemaccel, Normal Saline, Hartmanns solution etc.

Jehovahs Witnesses WILL Normally accept:

• Dextrose

• EPO (Recombinant Erythropoietin)

• G-CSF (granulocyte colony stimulating factor)

• Recombinant Factor VIIa (NovoSeven)

• Gelofusin

• Normal Saline, Hartmanns, Ringers Lactate

• Dextran

 Jehovahs Witnesses WILL NOT Normally accept:

• Whole Blood

• Red blood cells (packed cells)

• Platelets

• Fresh Frozen Plasma

• White blood cells (i.e. Granulocytes)

• Preoperative collection and storage of autologous blood

Individual Jehovahs Witnesses decision - May vary:

• Immunoglobulins (e.g. RhD immunoglobulin, CMV etc.)

• Factor VIII (i.e. Biostate)

• Clotting factors (i.e. Prothrombinex)

• Albumin

• Cryoprecipitate

• Surgical techniques which require the use of a continuous extracorporeal circuit

  -        Heart-lung bypass

  -        Renal Dialysis

  -        Haemofiltration

  -        Haemodilution

  -        Intra- and post-operative blood salvage and reinfusion

PRESCRIBING BLOOD AND BLOOD PRODUCTS

SINGLE UNIT TRANSFUSION

Patient Blood Management practices indicate that the transfusion of a single bag of blood, followed by clinical reassessment to determine the need for further transfusion, is appropriate.

Transfusion need should be assessed on an individual basis and single unit red cell transfusions should be considered in patients with low haemoglobin who are clinically stable with no active bleeding.  A second unit should only be considered after review of the patient which may include checking for

WRITING THE PRESCRIPTION

• All blood and blood products are to be prescribed on the Blood product prescription form MR/683.02.

• All sections must be completed by the prescriber, including the patient's transfusion history

• The prescription must be clear and legible and should include:

  -   patient identifiers x 3 (use patient label)

  -   the required product using approved and consistent terminology

  -   special modifications, if required

  -   dose

  -   rate of infusion

  -   route of administration

  -   reason for infusion (using the indication code number on form)

  -  name and signature of medical officer prescribing

• The chart can be used for multiple transfusion episodes during one admission

• The patient's response to the adminstration of the blood product must be documented in the medical record.

• Blood MUST NOT be prescribed as per protocol (APP), with the exception of intravenous immunoglobulin(IVIg). Blood (including FFP, Platelets and Cryoprecipitate) must be prescribed as an hourly rate that must not exceed 4 hours.

REQUESTING BLOOD PRODUCTS

A Blood Product Request Form must be completed to request issue of blood from pathology.  A valid group and screen is required for crossmatching prior to release of red cells. The group and screen sample is valid for up to 72 hours from collection, after which a further sample will be required to be sent.  Refer to POL0012 Blood Components - Crossmatching for Transfusion

All fractionated products i.e. those in glass bottles and vials are issued from pharmacy and the prescription must be sent to pharmacy.  In certain areas there may be imprest stock that can be accessed.

COLLECTION and DELIVERY OF BLOOD FROM PATHOLOGY

All blood will be issued from pathology, 2nd floor medical services building.

Blood components should only be collected from the laboratory immediately prior to administration.

How to collect blood from pathology

1. Notify pathology on ext 94357 that you will be collecting the blood, to ensure it is ready

2. Take the Blood product prescription form MR/683.02 with the patients name, date of birth and UR number clearly documented on the patient label, or an actual patient label. If written details are not presented at the laboratory, blood will not be released

3. Check that the blood issued by the scientist is the correct unit for the patient by checking patient's full name, UR number, date of birth on the tag, and also the donation number of the bag of blood. The scientist will complete the details on the laboratory blood stock issue report, including the ward that the blood will be taken to.

4. Transport the blood immediately to the ward or department in a red coloured esky (provided by pathology) and give to a Registered Nurse or Midwife

5. The esky is to be returned to pathology via the pathology 'samples for collection' box on each ward.

RETURNING BLOOD BAGS: for any patient in isolation (i.e. contact, droplet or airborne precautions)

• IF the product has been taken to the point of care (patient bedside/room) and can not be transfused for any reason, these components CANNOT be returned to the laboratory or blood fridge. They will need discarding as other contaminated waste.  (Blood product bags are semi-permeable cannot be wiped down with any sort of alcohol or other antiseptics).

• Please notify the laboratory if the product is not transfused and discarded to update records appropriately.

• If the blood product has NOT gone to the patient bedside/room and is not being transfused, it can be sent back to the laboratory if within the appropriate timeframe.

RECEIVING BLOOD WITH A PATIENT TRANSFER FROM ANOTHER ORGANISATION

Occasionally blood and blood products may arrive with a patient transferred from another hospital and these units should immediately be sent to the laboratory. However, the patients presenting condition may necessitate that these units are transfused urgently. This will be the sole responsibility of the treating clinician to make this decision. 

If not used the following procedure must be followed:

• Contact the blood bank scientist to advise them of the arrival of the blood

• Take a blood sample for crossmatch from the patient.  This will ensure the rapid provision of further blood if required

• Send the blood still packaged as it arrived at the hospital, to the laboratory.  This will allow the laboratory to confirm whether the units have been correctly packaged for transport and will be suitable for transfusion.

• WARNING: Blood that has not been packaged correctly for transport has an increased risk of haemolysis and bacterial proliferation and is dangerous to use

EMERGENCY BLOOD TRANSPORT SYSTEM

• The Blood in Motion is a system for transporting blood and maintaining it at the correct temperature to prevent unnecessary wastage during an emergency, or at times when it may be required on standby.

• It consists of an esky and pre-cooled modules that will maintain red cells at a temperature of between 2 8C (as indicated on the temperature logger), for at least 4 hours providing the modules are not removed from the esky.

• The esky can hold a maximum of 4 units of red cells and 4 bags of FFP inside the bag and 1 bag of platelets, stored in a pocket on the outside.  Cryoprecipitate may also be packed

Why use the Blood in Motion system?

• Constant temperature control providing the blood is not removed from the unit until required

• Helps reduce wastage if red cells are out of refrigeration for > 30 minutes

• Timeframe to safely transfuse is increased, allowing greater flexibility in transfusion decisions

• Allows blood to be available for use during an emergency

Important information

• Module is pre-cooled in the laboratory prior to placing in esky

• Fluid in the module will look solid at correct temperature, becoming liquid as temperature increases

• Modules are NOT to be placed in any ward or department refrigerator

• The complete system MUST be returned to the laboratory on completion of transfusion or if blood is no longer required

• Surface can be wiped down with disinfectant as necessary

Note: The Blood in Motion bag is for internal use at Ballarat Health Services. It must not be used to transport blood to external organisations or via ambulance or helicopter. If blood is required in these instances, pathology must be notified and asked to pack the blood according to the Blood Service standard operating procedures. This will ensure that the blood products are packaged to maintain cold chain processes and be accepted at the receiving hospital if not used en route.

TRANSFUSION PROCEDURE

 INDICATIONS

Any time a blood component is to be transfused the following procedure must be adhered to.  Consent must be obtained prior to transfusion commencing. Non-emergency transfusion must not commence if a consent form has not been completed.

EQUIPMENT

• IV Pole

• Electronic infusion pump (Alaris Carefusion Pump +/- Guardrails)

• Blood giving set for pump with 170 - 200 micron in-line filter. i.e. Alaris Blood giving set

• 0.9% Normal Saline 10 mL ampoule

• Prescription written on Blood product prescription form MR/683.02

• Completed Transfusion Consent form

• Adult Observation and Response Chart (appropriate to each area)

• Blood crossmatch compatibility report (issued from pathology

• Personal protective equipment gloves, goggles.

Other giving sets available:

• Alaris Transfusion Blood Set. Vented with 200 micron filter (gravity feed)

• Alaris Blood/Solution Pump Set (gravity feed with hand pump if required)

• Braun Sangofix ES Blood administration set with in-line filter 200 microns (gravity feed)

ISSUES TO CONSIDER

CONCURRENT FLUIDS AND MEDICATIONS

COMPATIBILITY BETWEEN BLOOD GROUPS

Red cells

Blood Group

If patients Blood Group is:

                  Group A they can have A and O

                  Group B they can have B and O

                  Group AB can have AB, A, B, or O

                  Group O can have O

RhD Status

      RhD positive should only be given to RhD positive patients.

      RhD negative can be given to RhD negative and RhD positive patients

(Note: In times of blood shortages RhD positive blood may be issued to RhD negative men and RhD negative women of non-childbearing age. If this occurs consideration should be given to the administration of RhD immunoglobulin to prevent RhD immunization).

Platelets

       Platelets should preferably be ABO and RhD type compatible with the recipient. However ABO incompatible platelets may be used if ABO compatible platelets are not available.

       If RhD positive platelets are transferred to an RhD negative female of child-bearing potential, RhD immunoglobulin (Anti-D) should be considered to prevent RhD immunisation.

FFP / Cryoprecipitate

FFP is issued on the patients ABO group only Rh status is NOT relevant.

                 Group A can have A and AB

                 Group B can have B and AB

                 Group AB can have AB

                 Group O can have O, AB, A, B

Cryoprecipitate will preferably be issued on the patients ABO group when possible. However, ABO-incompatible cryoprecipitate can be used with caution, particularly with large volumes.

ADMINISTRATION LINE / GIVING SETS / PUMPS

• All giving sets for blood component transfusions must have an in-line filter of 170-200 micron.

• The Alaris Carefusion Pumps using the Alaris blood giving set are suitable to transfuse red cells and platelets and will not damage cells as long as the following flow rates are not exceeded:

  Red cells: maximum rate 999 ml/hr

  Platelets: maximum rate 999 ml/hr, but preferably run via gravity feed

  FFP can be infused via a pump

        

• Cryoprecipitate should be gravity fed.

 NEONATAL TRANSFUSIONS

The principles of transfusion practice are identical for all patients. Blood transfusion should only occur when the benefits of transfusion outweigh the risks.  Signed consent must be obtained from the parent, and an information package offered.  Transfusion should not occur overnight. 

Transfusion volume is dependent on the infants weight and should have the volume prescribed in mL.

Formula for calculating transfusion volume for neonates and children

Packed cells (mls) = wt (kg) x Hb rise required (g/L) x 0.4

(e.g 10kg child requiring Hb to rise from 60 to 110g/L - 10 x 50 x 0.4 = 200mL)

It is preferable that all red cells for transfusion to neonates be irradiated within the previous 24hrs prior to transfusion.

Fresh red cells (less than 5 days old), K negative, CMV negative may also be indicated.

Equipment

• Alaris Carefusion pump with Guardrails

• Alaris Neonatal Closed Blood set

• 50ml Terumo luer lock syringe

• Sterile gauze swabs

• Sterile field

Note:  The Pall Posidyne Neo Filter must not be used when transfusing red cells or platelets

Observation

Temperature, pulse and respirations (TPR) must be taken and recorded on the Observation and Response Chart, clearly indicating when the transfusion was commenced and finished.

• Before the start of each pack of blood or blood product

• 15 minutes after blood product reaches access point/vein

• Then hourly throughout the transfusion

• At completion

Note: Infants and neonates will not be able to communicate adverse effects of transfusion and therefore must be closely monitored. Remain with patient for the first 15 minutes as life-threatening reactions can occur after the infusion of a small amount of blood. Signs and symptoms of acute reactions may present differently in infants and paediatric patients, and can include irritability, agitation and inconsolability by the parent or main caregiver.  These signs and symptoms may be present in the abscence of or before changes in vital signs.

PAEDIATRIC TRANSFUSIONS

• Ballarat Health Services Paediatric Department follows the Royal Childrens Hospital Transfusion Guidelines: www.rch.org.au/blood trans Signed consent must be obtained from the parent, and an information package offered.  Transfusion should not occur overnight. 

Observation

TPR and BP must be taken and recorded on the Observation and Response Chart, clearly indicating when the transfusion was commenced and finished.

• Before the start of each pack of blood or blood product

• 15 minutes after blood product reaches access point/vein

• Then hourly throughout the transfusion

• At completion

LOCATION AND TIMING OF THE TRANSFUSION

• It is recommended that the safest and best time for a patient to receive an elective blood transfusion is between the hours of 7am and 8pm.  Blood may be given outside these hours if it is a medical emergency or in a critical care area (ICU, Emergency and Theatre).

• Transfusions should only take place in ward or department areas where there is ongoing supervision of the patient.  Patients should not leave the ward area while receiving a transfusion.

• All transfusions must be completed within 4 hours of spiking the bag or 4 1/2 hours after release from cold storage.

BLOOD TRANSFUSION DURING DIALYSIS

• Transfusion during dialysis is given via the extracorporeal blood line

• One unit of packed cells may be transfused during a dialysis treatment

• To avoid hyperkalaemia, transfuse blood pre-dialyser so potassium is removed via filtration 

CHECKLIST PRIOR TO COLLECTION OF THE BLOOD PRODUCT

Prior to ordering or collecting the blood check the following:

• The patient is aware of the procedure, understands what is to occur and has agreed to have the transfusion. Check that consent has been obtained and documented by the medial officer.

• Written orders have been completed.

• The patient has patent venous access.

• A baseline set of vital signs has been taken and recorded.  If there are any concerns e.g. the patient has become febrile, make sure this is acted upon.

• Any premedication required has been given

• The patient is not expected off the ward for other procedures (there may be exceptions)

• Staff have time to monitor the patient

PATIENT AND BLOOD COMPONENT IDENTIFICATION

The final identity check is the final opportunity to detect an identification error and prevent the potential for an incompatible transfusion reaction, which may be fatal.

All patients and blood components must be identified and checked independently, at the bedside, by 2 members of staff immediately prior to blood administration. Both staff members must view each identifier independently, in the presence of the other staff member. This check includes comparison of details on the patient identification wristband, compatibility tag, blood component and medical orders to ensure these are identical (see checklist below).
Staff who may check blood products:

• Registered Nurse

• Registered Midwife

• Enrolled Nurse (within their scope of practice), may only check with another RN/RM.

• Medical Officer

Note: the patient's allocated nurse is to administer the blood components wherever possible or ensure that a handover for the clinical indication of the administration has occurred.

All patients receiving blood and blood products must be wearing an identification band that includes full name (family name and at least first given name), UR number and date of birth. This applies to both inpatients and patients being treated in outpatient or day areas, with the exception of patients in Dialysis where photographic identification is used.

In the conscious patient active positive identification of the patient must be established by:

• Asking the patient to state their full name and date of birth and checking these are identical to the information on their identification wrist band and the blood component compatibility tag.

In the unconscious or confused patient identity can be established by

• Using the patient identification wrist band

For the patient in isolation:

• The Blood product prescription orders form (MR/683.02) must be taken into the patient's room and the two staff members completing the check must check this against the patient identification wrist band and blood product. Correct application of PPE (Personal Protective Equipment) and hand hygiene must be practiced pre and post glove removal/patient contact

For the emergency patient who requires blood due to critical bleeding prior to the admission and identification process:

• In this situation the patient will be given O negative emergency units.

• Once the identity has been established (including "unknown" patient identifiers) the patient must be given identification band and blood products are checked against this.

     IMPORTANT NOTICE TO ALL STAFF

Under NO circumstances is the use of passive identification (bed cards, patient notes, bed/cubicle number, patient familiarity etc.) be used to identify patients having any blood products.

Using this process of identification is DANGEROUS and places the patient at high risk of receiving the wrong unit of blood which could be fatal.

PATIENT AND BLOOD COMPONENT IDENTIFICATION CHECKLIST

The simultaneous, independent checking procedure involves checking the following details (both staff members must view each identifier independently, in the presence of the other staff member). ALL DETAILS MUST BE CORRECT AND IDENTICAL BEFORE THE UNIT IS ADMINISTERED TO THE PATIENT. Where there is any discrepancy in information this MUST be corrected prior to the transfusion taking place.

1. Check Patient Identification

2. Check ABO Group

3. Check Product Details

One of the two staff performing the checks must then spike the blood bag and commence the transfusion, immediately after the checks have been completed.

PROCEDURE

PLEASE ENSURE THAT THE APPROPRIATE SECTION ON THE RELEVANT BLOOD COMPONENT HAS ALSO BEEN READ.

RESPONDING TO AND REPORTING REACTIONS

Follow Blood product transfusion reaction guide on page four of MR/683.02 (Blood product bedside check & transfusion reaction guide)

 TRANSFUSION REACTIONS

• Blood transfusion reactions can be fatal.

• Signs and symptoms should be acted upon immediately

• Be aware that clinical symptoms, not changes in vital signs, may be the first indication of a transfusion reaction.

Delayed reactions occur >24 hours after transfusion and include:

• Delayed haemolytic reactions

• Post-transfusion purpura (PTP)

• Transfusion transmitted infections (not bacterial)

• Transfusion associated graft versus host disease (Ta-GVHD)

• Iron overload

 SIGNS AND SYMPTOMS (of acute reactions)

These will vary according to the type of blood component being transfused and type of reaction, but include:

Other complications that may occur are

•  Metabolic complications: may occur when very large amounts of blood are transfused. May include

-        Hypothermia                          -  Acidosis

-        Citrate toxicity                        -  Hypo / hyperkalemia

If the only feature is a rise in temperature to 38 C and at least 1C from baseline or an urticarial rash:

      recheck that the right blood is being transfused

      give paracetamol for fever

      give antihistamine for urticaria

      recommence the transfusion at a slower rate

      observe more frequently than routine practice.

Investigations that may be required: Refer to Acute Transfusion Reactions Poster (Appendix 2)

Initially send:

1. Pink cross match tube

2. Urine sample (first urine passed)

3. Blood Cultures if patient is febrile

Depending on results of the inital samples the following may be required:

 Note: Take care not to contaminate the blood component and attached giving set when sending to pathology for transfusion reaction investigation. This may impact on any microbiology test taken from the product. Consult with pathology on ext: 94357 if unfamiliar with the appropriate specimens required for the investigation of the reaction.

TRANSFUSION INCIDENTS

All incidents or near miss events involving blood components or products must be reported as soon as possible using the hospital reporting system (VHIMS).
The Blood Matters program Serious Transfusion Incident Reporting (STIR) system is a voluntary system to capture serious hospital transfusion incidents, including near misses. The data is collated, aggregated and reported with recommendations for improvements for better, safer transfusion practice.

The Transfusion Nurse Consultant investigates all reported VHIMS incidents and reports those that meet STIR guidelines to the Blood Matters Program. Blood Matters: Serious Transfusion Incident Reporting guide, revised 2017