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Blood transfusion

1. BLOOD & BLOOD TRANSFUSIONS

2. BLOOD blood and blood transfusions 2

3. Blood is considered as river of life, fluid of life, fluid of growth, fluid of health. Average human has 5 liters of blood i.e 8% of total body weight. It is a transporting fluid. It carries vital substances to all parts of body. 3 blood and blood transfusions

4. Properties Of Blood Color range Oxygen-rich blood is scarlet red bright crimson Oxygen-poor blood is purple red. Red color comes from the several million red cells, present in it pH must remain between 7.35–7.45 Temp 38 c or 100.4 F 4 blood and blood transfusions

5. Blood is 5 times more viscous than water. Blood is a specialized type of connective tissue in which living blood cells, (formed elements), are suspended in a non living fluid matrix called plasma. Cellular Part (Formed Elements) Non cellular part (Plasma) 5 blood and blood transfusions

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7. Functions of plasma Helps in transport of substances in the body Maintains colloid osmotic pressure of blood Causes blood clotting because it contains the fibrinogen and prothrombin Stores proteins for supply in needs Helps provides viscosity to blood Contains antibodies and antitoxins 7 blood and blood transfusions

8. RED BLOOD CELLS RBCs are also called erythrocytes . They are tiny (7.5u in diameter, 2u thick) biconcave discs . They survive for about 120 days. RBCs are non nucleated formed elements in the blood. The average normal RBC count is – for men 5.4 million/ uL for women 4.5 million/ uL 8

9. Hemoglobin is the most important component of red blood cells. It is composed of a protein called heme , which binds oxygen. In the lungs, oxygen is exchanged for carbon dioxide. Abnormalities of an individuals hemoglobin value can indicate defects in red blood cell balance. Both low and high values can indicate disease states. 9 blood and blood transfusions

10. PLATELETS The platelets are tiny bodies, 2-4um in diameter. There are about 0.25 to 0.4 million/ uL of circulating blood. They have a half life of about 7 days. blood and blood transfusions 10

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12. OBJECTIVES Provide overview of transfusion therapy. Describe pre-transfusion responsibilities. Describe transfusion responsibilities. Describe post-transfusion responsibilities. Describe types of transfusions. Describe transfusion reactions. Describe autologous transfusions. blood and blood transfusions 12

13. OVERVIEW It is a procedure in which a patient receives a blood product through an intravenous line. It is the introduction of blood components into the venous circulation. Process of transferring blood-based products from one person into the circulatory system of another. blood and blood transfusions 13

14. HISTORY OF BLOOD TRANSFUSION Before The Nobel Prize awarded, Karl Landsteiner discovered the ABO human blood groups in 1901, it was thought that all blood was the same. This misunderstanding led to fatal blood transfusions and many death. blood and blood transfusions 14

15. Prof. Karl Landsteiner discovered that blood clumping was an immunological reaction Karl Landsteiner's work made it possible to determine blood types For this discovery he was awarded the Nobel Prize in Physiology or Medicine in 1930. blood and blood transfusions 15

16. A person has 5 - 6 liters of blood in their body. A person can donate blood every 90 days (3 months). Body recovers the Blood very quickly: Blood plasma volume– within 24 - 48 hours Red Blood Cells – in about 3 weeks Platelets & White Blood Cells – within minutes blood and blood transfusions 16

17. Purposes To replace losses of: Circulating volume Oxygen carrying capacity . To restore: Metabolic homeostasis. To replenish: Normal RBC’s ( eg . Refractory anemias , Thalasemias , Sickle cell anemias etc) In cancer patients like ALL; AML; with / orafter Chemothrapy drugs For emergency surgery, heart surgery blood and blood transfusions 17

18. Typical Situations in which blood products are given Major injuries after an accident or disaster Surgery on an organ such as the liver and the heart Severe Anemia Bleeding such as Haemophilia and Thrombocytopenia Pre-mature, pre term babies Cancer patients blood and blood transfusions 18

19. What are the different blood groups? There are more than 20 genetically determined blood group systems known today The AB0 and Rhesus ( Rh ) systems are the most important ones used for blood transfusions. Not all blood groups are compatible with each other. Mixing incompatible blood groups leads to blood clumping or agglutination, which is dangerous for individuals. blood and blood transfusions 19

20. ABO blood grouping system According to the ABO blood typing system there are four different kinds of blood types: A, B, AB or O (null). blood and blood transfusions 20

21. The Rhesus ( Rh ) System Well, it gets more complicated here, because there's another antigen to be considered always - the Rh antigen . Some of us have it, some of us don't have. If it is present, then blood is RhD positive, if not it's RhD negative. So, for example, some people in group A will have it, and will therefore be classed as A+ (or A positive). While the ones that don't, are A- (or A negative). And so it goes for groups B, AB and O. blood and blood transfusions 21

22. A person with Rh - blood can develop Rh antibodies in the blood plasma if he or she receives blood from a person with Rh + blood, whose Rh antigens can trigger the production of Rh antibodies. A person with Rh + blood can receive blood from a person with Rh - blood without any problems. blood and blood transfusions 22

23. blood and blood transfusions 23 Blood Group Antigens Antibodies Can give blood to Can receive blood from AB A and B None AB AB, A, B, O A A B A and AB A and O B B A B and AB B and O O None A and B AB, A, B, O O

24. Rh + can receive blood from: Rh + and Rh - Rh - can receive blood from: Rh - only blood and blood transfusions 24

25. BLOOD BANKS Blood banks collect, test, and store blood. Autologous transfusion - If surgery is scheduled months in advance, patients may be able to donate their own blood and have it stored. blood and blood transfusions 25

26. BLOOD STORAGE Blood products must be stored at 4 C ± 2 C . Stored blood has a shelf life of 3 weeks. After a storage time of 24-72 hr RBCs have reduced capability to release oxygen to tissues. If the patient needs massive transfusions its better to give blood that’s less than 7 days old. blood and blood transfusions 26

27. Requesting Procedure Check the patient’s case note Transfusion history Special requirements e.g., irradiated, CMV negative Complete request form or order communications blood and blood transfusions 27

28. blood and blood transfusions 28 Casenote Surname Forename DOB Ethnic Origin Location Consultant Sex Patient Category NHS Date of Request Entered by Originator Date of Specimen Service (Type of Request) Blood Group Previous Transfusion Units (amount) Date Reqd Reaction Specimen type Vacutainer 7mls pink + 4.5 mls EDTA Antibodies Specimen taken by Sign and print Name Requesting Medic Sign and Print name Copy of this request must be filed in the notes. See Trust Transfusion policy Diagnosis, referral reason, relevant medication Information found on the Request Forms

29. PRE-TRANSFUSION RESPONSIBILITIES Assess laboratory values Verify the medical prescription. Assess the client’s vital signs, urine output, skin color and history of transfusion reactions . Obtain venous access. Use a central catheter or at least a 20-gauge needle, if possible . blood and blood transfusions 29

30. Sampling Procedure Step 1: Ask the patient to tell you their: Full Name + Date of Birth Check this information against the patient’s ID wristband Be extra vigilant when checking the identity of the unconscious / compromised patient blood and blood transfusions 30

31. Step 2: Check the patient’s ID wristband against documentation e.g., case notes or request form for: • First name • Surname • Date of birth • Hospital number blood and blood transfusions 31

32. Sampling Procedure Only bleed one patient at a time using Aseptic non touch technique Do NOT use pre-labeled tubes Label the sample tube beside the patient Send the sample to the laboratory in the most appropriate way for the clinical situation, i.e. routine / emergency Remember emergency requests must always be phoned through to the Transfusion Laboratory. blood and blood transfusions 32

33. Labelling the venous blood sample Information to include:- Full name Date of birth Hospital number Gender Date Signature of person who has taken the sample At the bedside By the person taking the sample blood and blood transfusions 33

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35. IV Blood/ Blood Component Chart blood and blood transfusions 35

36. Prescribing a transfusion Each unit must be entered separately on the patient’s prescription sheet. The entry must specify the type of product any special requirements the rate of transfusion – max 4hrs/unit blood and blood transfusions 36

37. Blood Transfusion Administration blood and blood transfusions 37

38. Obtain blood products from a blood bank; transfuse immediately. With another registered nurse, verify the patient by name and number, check blood compatibility and note expiration time. Administer the blood product using the appropriate filtered tubing. blood and blood transfusions 38

39. Good Documentation Minimum Transfusion Dataset: the following should be documented in the notes Reason for transfusion Current blood results Component type and amount to be prescribed Anticipated outcome Any reported transfusion adverse events/reactions Review following the transfusion including how much blood has been transfused blood and blood transfusions 39

40. Warming Blood STORED BLOOD IS COLD 4*C PATIENTS UNDERGOING SURGERY WILL ALREADY BE LOSING BODY HEAT DUE TO WOUND OR CAVITY EXPOSURE LARGE VOLUMES OF COLD BLOOD MAY INDUCE HYPOTHERMIA OR CARDIAC ARYTHMIA blood and blood transfusions 40

41. A t infusion rates>100ml/minute, cold blood may be a contributing factor in cardiac arrest. However, keeping the patient warm is probably more important than warming the infused blood ! Warmed blood is most commonly required in largevolume rapid transfusions & exchange transfusion in infants. Blood should only be warmed in a blood warmer that have a visible thermometer and an audible warning alarm and should be properly maintained . blood and blood transfusions 41

42. Can the Patient be Safely Transfused ? Is the product clearly prescribed? Are any drugs required before or during transfusion? i.e. antibiotics Is the rate of transfusion appropriate? Does the patients condition require medical review prior to transfusion All patients having a blood transfusion MUST have a NAMEBAND containing all of their required details blood and blood transfusions 42

43. Monitoring of Patient Base line observations – Temperature, pulse and blood pressure Further observations (as above) at 15 minutes A set of observations at the end of transfusion More frequently if the patient is unwell, unobservable, unconscious or a child. blood and blood transfusions 43

44. MONITORING PATIENTS Ensure the venflon is secure, patent and there are no signs of inflammation Give the patient the call bell Patients should remain in a clinical area for the duration of the Transfusion Review the patients fluid balance and medication. blood and blood transfusions 44

45. Pre-administration Procedure Step 1: Check the blood component has been prescribed Step 2: Undertake baseline observations Step 3: Undertake visual inspection blood and blood transfusions 45 LEAKS DISCOLOURATION CLUMPING EXPIRY DATE

46. Pre-administration checks Personal checks: - ANTT - wear personal protective equipment Equipment checks: - Personal protective equipment is available and is clean and sterile - A correctly completed prescription chart - Observation chart - Giving set - Disposable bags - Trolley blood and blood transfusions 46

47. Administration Procedure Step 1: Ask the patient to tell you their Full Name + Date of Birth Check this information against the patient’s ID wristband blood and blood transfusions 47

48. Administration Procedure Step 2: C heck the patient’s First name Surname Date of birth Hospital number on the compatibility/ traceability label against the patient’s ID wristband blood and blood transfusions 48

49. Administration Procedure Step 3: Check the compatibility/traceability label with the blood bag label blood and blood transfusions 49 Any discrepancies DO NOT TRANSFUSE !

50. Blood Component Bedside Check Procedure blood and blood transfusions 50 SURNAME FIRST NAME(s) HOSPITAL NUMBER D.O.B.BLOOD GROUP (Patient and Unit) DONOR NUMBER EXPIRY DATE Special Requirements

51. Remain with the patient during the first 15-30 minutes of the infusion. Infuse the blood product at the prescribed rate. Monitor vital signs. blood and blood transfusions 51

52. Reporting Incidents/Transfusion Reactions Stop the Transfusion and seek Medical Input and inform the Transfusion Laboratory staff Check the Blood component matches the patient details Replace the unit and giving set with Normal Saline 0.9% Send the discontinued unit with giving set attached back to transfusion capped off at the end with a white venflon cap – and any previous transfused bags sealed with the blue plugs all in biohazard bags Documentation (complete the checklist) Complete a Trust Incident form blood and blood transfusions 52

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54. TYPES OF TRANSFUSION blood and blood transfusions 54

55. Types of BT Based on time of transfusion Fresh whole blood transfusion Stored CPD Blood Based on composition Whole blood Blood fraction Based on the donor Autologous blood transfusion Blood from diff donor blood and blood transfusions 55

56. Whole Blood Packed Red Blood Cells Platelet Rich Plasma Slow Centrifugation High Speed Centrifugation 1 Unit of Random Donor Platelets 1 Unit of Fresh Frozen Plasma Cryoprecipitate Thawing precipitates the plasma proteins BLOOD COMPONENTS

57. Whole Blood Storage 4 ° for up to 35 days Indications Massive Blood Loss/Trauma/Exchange Transfusion Considerations Use filter as platelets and coagulation factors will not be active after 3-5 days Donor and recipient must be ABO identical

58. RBC Concentrate Storage 4 ° for up to 42 days, can be frozen Indications Many indications—ie anemia, hypoxia, etc. Considerations Recipient must not have antibodies to donor RBC’s (note: patients can develop antibodies over time) Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl) Usually transfuse over 2-4 hours (slower for chronic anemia

59. Platelets Storage Up to 5 days at 20-24 ° Indications Thrombocytopenia, Plt <15,000 Bleeding and Plt <50,000 Invasive procedure and Plt <50,000 Considerations Contain Leukocytes and cytokines 1 unit/10 kg of body weight increases Plt count by 50,000 Donor and Recipient must be ABO identical

60. Plasma and FFP Contents—Coagulation Factors (1 unit/ml) Storage Comes in 200ml bags. FFP--12 months at –18 degrees or colder Indications Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusion Considerations Plasma should be recipient RBC ABO compatible In children, should also be Rh compatible Account for time to thaw Usual dose is 20 cc/kg to raise coagulation factors approx 20%

61. Cryoprecipitate Description Precipitate formed/collected when FFP is thawed at 4 ° Storage After collection, refrozen and stored up to 1 year at -18 ° Indication Fibrinogen deficiency or dysfibrinogenemia vonWillebrands Disease Factor VIII or XIII deficiency DIC (not used alone) Considerations ABO compatible preferred (but not limiting) Usual dose is 1 unit/5-10 kg of recipient body weight

62. Granulocyte Transfusions Prepared at the time for immediate transfusion (no storage available) Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected Donor is given G-CSF and steroids or Hetastarch Complications Severe allergic reactions Can irradiate granulocytes for GVHD prevention

63. Leukocyte Reduction Filters Used for prevention of transfusion reactions Filter used with RBC’s, Platelets, FFP, Cryoprecipitate Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions May reduce RBC’s by 5-10% Does not prevent Graft Verses Host Disease (GVHD)

64. RBC Transfusions Preparations Type Typing of RBC’s for ABO and Rh are determined for both donor and recipient Screen Screen RBC’s for atypical antibodies Approx 1-2% of patients have antibodies Crossmatch Donor cells and recipient serum are mixed and evaluated for agglutination

65. RBC Transfusions Administration Dose Supplied in 250ml bags. Usual dose of 10 cc/kg infused over 2-4 hours Maximum dose 15-20 cc/kg can be given to hemodynamically stable patient Procedure May need Premedication (Tylenol and/or Benadryl) Filter use—routinely leukodepleted Monitoring—VS q 15 minutes, clinical status Do NOT mix with medications Complications Rapid infusion may result in Pulmonary edema Transfusion Reaction

66. Platelet Transfusions Preparations ABO antigens are present on platelets ABO compatible platelets are ideal This is not limiting if Platelets indicated and type specific not available Rh antigens are not present on platelets Note: a few RBC’s in Platelet unit may sensitize the Rh- patient

67. Platelet Transfusions Administration Dose May be given as single units or as apheresis units Usual dose is approx 4 units/m 2 —in children using 1-2 apheresis units is ideal 1 apheresis unit contains 6-8 Plt units (packs) from a single donor Procedure Should be administered over 20-40 minutes Filter use Premedicate if hx of Transfusion Reaction Complications—Transfusion Reaction

68. Autologous Blood Transfusions Collection/infusion of client’s own blood Four types: Preoperative autologous blood donation Acute normovolemic hemodilution Intra-operative autologous transfusion Postoperative blood salvage blood and blood transfusions 68

69. Preoperative autologous blood donation Collecting whole blood from the client, dividing it into components and storing it for later use Can be collected weekly as long as client’s H&H are within safe range Can be stored up to 40 days; up to 10 years for rare blood types. blood and blood transfusions 69

70. Acute normovolemic hemodilution Withdrawal of client’s RBCs and volume replacement just before a procedure Goal is to decrease RBC loss during surgery Blood is stored at room temperature for up to 6hrs and reinfused after surgery. Not for anemic clients or those with poor kidney function. blood and blood transfusions 70

71. Intra-operative autologous transfusion & Post operative blood salvage Recovery/reinfusion of client’s own blood from operative field or bleeding wound. Special devices collect, filter, drain blood into transfusion bag Used for trauma or surgical patients with severe blood loss Blood must be reinfused within 6 hours. blood and blood transfusions 71

72. TRANSFUSION REACTIONS blood and blood transfusions 72

73. Observing / Monitoring the Patient During a Blood / Blood Component Transfusion is part of safe transfusion Rigors Haemoglobinuria Tachycardia Hyper / Hypotension Pyrexia Nausea / vomiting Breathlessness / coughing Restlessness Agitation Confusion Chest, abdominal, muscle, bone or loin pain Flushing Urticaria - Itchy rash Headache Collapse Generally feeling unwell

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79. Transfusion-associated graft-versus-host disease (TA-GVHD). Donor T-cells attack host tissues. Symptoms occur within 1-2 weeks Thrombocytopenia Anorexia Nausea Vomiting Chronic hepatitis Weight loss Recurrent infection blood and blood transfusions 79

80. DISSEMINATED INTRAVASCULARCOAGULATION(DIC) DIC is the abnormal activation of the coagulation and fibrinolytic systems,resulting in the consumption of coagulation factors and platelets. DIC may develop during the course of massive blood transfusion,although its cause is less likely to be due to the transfusion itself than related to the underlying reasons for transfusion,such as: Hypovolaemic shock Trauma Obstetric complications blood and blood transfusions 80

81. MANAGEMENT Treatment of DIC should be directed at correcting the underlying cause and at correction of the coagulation problems as they arise. blood and blood transfusions 81

82. Transfusions of blood & blood components are labour intensive & expensive but are frequently life saving In a few patients, however they can result in potentially fatal complications. It is therefore essential that they are only given when the benefits outweigh the risks Conclusion

83. THANX blood and blood transfusions 83