Safe blood transfusion practices and policy of hospital

1. SAFE BLOOD TRANSFUSION PRACTICES AND
POLICY OF HOSPITAL CHANGKAT MELINTANG
DR LEE OI WAH
PENGARAH
HCM

2. INTRODUCTION
•Blood transfusion is a safe process that
saves lives and improves the quality of life
in a large range of clinical conditions.
•But there are a number of risks associated
with transfusion as with any other clinical
intervention.

4. •More recently in 2003, SHOT recommended that
health care staff should receive transfusion
procedures training and formally assessed
competency that is recorded if they contribute to
the transfusion process (SHOT, 2003).
•REASON ???

5. Summary of UK Transfusion Practice Audit Results
(Gray, Buchanan, McClelland, 2003;
RCP/NBS, 2003)

✦
18% of patients had no identification check
when the pre-transfusion sample was taken.

✦
11% of blood components collected had no
patient minimum data set check.

✦
10% of patients were not wearing a wristband
during their transfusion.

✦
47% of patients had no vital signs monitored
within the first 30 minutes of the transfusion

6. Typical SHOT IBCT errors (SHOT, 2004)

✦
The blood sample was drawn from the wrong
patient.

✦
Patient details were recorded incorrectly on the
blood sample label or the blood request form.

✦
The incorrect unit was collected from the blood
refrigerator.

✦
The formal identity check at the patient’s bedside
was omitted or performed incorrectly at the time of
the administration of the blood component.

7. THE TRANSFUSION PROCESS
•Every hospital must have policies and
procedures in place for every step in the blood
transfusion process which includes :
Consent(informing the patient)
Sampling
Collection of blood bag
Pre-administration
Administration
Patient monitoring
Technical aspect of blood transfusion

8. INFORMING THE PATIENT
“Every patient has a fundamental legal and ethical right
to determine what happens to his or her own body.”
•When you care for a patient who is about to undergo a
blood transfusion, you should:

✦
inform the patient about the intended transfusion
therapy and give them the opportunity to discuss it
and raise any concerns that they may have

✦
check that the decision to transfuse is recorded in the
patient case notes before administering the blood
component.

✦
check that a written consent is obtained form patient
for each pint of blood transfused.

9. SAMPLING
•“Every patient who may require a transfusion during
an inpatient or day patient episode will wear an
identity band on which is recorded legibly the
patient’s correct minimum identification data.”
•Patient minimum identification data set

✦
Name(s)

✦
Identification No/Passport No

10. When you take a blood sample, you should:

✦
ask the patient to state their first name, surname, and
identification No to check that you have the right patient before
you draw the sample.
✦ask another member of staff, relative or carer to verify the patient
identification details if the patient is unable to do this, for
example, because they are unconscious or a child.
✦ check the details against the patient’s identity
wristband

✦
collect the required amount of blood into the appropriate sample
tube.
✦ after you have drawn the blood sample and before you leave the
patient, label the compatibility sample tube clearly and accurately
with the patient details that you have taken from the identity
wristband

✦
check that the patient details on the sample tube and request
form correspond

✦
send the blood sample tube and request form to the hospital
transfusion laboratory (HTL) with the appropriate request date
and time.

11. COLLECTION
•You should ensure that every blood component collected is checked against
the patient’s minimum identification data set.
•

✦
check that the details on the blood collection form, or local
documentation,match the information on the patient’s wristband
before passing the request to the person collecting the blood
component

✦
check the patient’s identification details on the blood collection form, or
local documentation, against the patient compatibility label on the
blood component that you have just collected

✦
document the removal of the unit of blood by putting the date, time and
signature of the person removing it onto the blood fridge register or
electronic release system

✦
inform the person who requested the blood component that it has arrived
as soon as it is delivered.

12. PRE-ADMINISTRATION
You should check that the:

✦
patient understands the process and why the transfusion is being
given, and explain the procedure fully

✦
blood component has been prescribed appropriately

✦
baseline observations of temperature, pulse and blood pressure
are undertaken before starting the transfusion of each unit of
blood

✦
expiry date of the blood component is correct, and undertake a
visual inspection for any signs of discoloration, clumping or leaks.
You also need to check if the patient has any special requirements,
such as a diuretic.

14. ADMINISTRATION
•You should ensure that every individual who needs a
blood transfusion as an inpatient or day patient has a
final identity check:

✦
positively identify the patient (see Box 2) using an open
question “can you tell me your full name?

✦
ask another member of staff, relative or carer to
verify the patient identification details if the
patient is unable to do this if, for example, they
are unconscious or a child.

✦
check these details against the patient’s
wristband for accuracy

15. ADMINISTRATION
✦ check that the blood group and the donation number on
the compatibility label are identical to the blood group
and donation number on the blood component.

✦
If there are any discrepancies at this point, it is important
that you do not proceed until they have been resolved.

✦
If you are interrupted in the checking procedure, you
must start again.

✦
You must wash your hands, and follow your local
infection control policy when you administer blood
components.

16. PATIENT MONITORING
•You should ensure that every patient who receives a
transfusion is monitored throughout the process.
•Good record keeping is the mark of a skilled and safe
practitioner.
•YOU SHOULD :

✦
ensure that the patient is in a setting where they can be
closely observed

✦
advise and encourage your patient to notify you
immediately if they begin to feel anxious, or if they
become aware of any adverse reactions such as
shivering, flushing,pain or shortness of breath

17. PATIENT MONITORING

✦
monitor the patient’s temperature and pulse 15 min
after you begin the transfusion of each unit, and
record them on the transfusion observation chart.

✦
adjust the flow-rate so that you achieve the correct
infusion rate over the prescribed time period.

✦
continue routine observations throughout the transfusion
for an unconscious patient: temperature, pulse, blood
pressure, and urinary output.

✦
document the start and finish times of each unit

✦
record the volume of blood transfused on the fluid
balance chart, or 24-hour chart

18. ✦
document the donation number, component type, and
date transfused of each blood component transfused in
the patient’s case notes.
If you suspect a transfusion reaction:

✦
stop the transfusion and immediately inform the doctor

✦
if the reaction appears life-threatening, call the
resuscitation team

✦
record the adverse event in the patient case notes

✦
report the adverse event in accordance with the hospital
policy.

19. TECHNICAL ASPECT OF BLOOD
ADMINISTRATION

✦
The size of the cannula depends on the size of the vein
and the speed at which the blood is to be transfused.

✦
Blood components must be transfused through a blood
administration set with an integral mesh filter (170–
200μm pore size).
✦ Blood warmers can be used for blood components
provided that they are specifically designed for that
purpose, and include a visible thermometer and audible
alarm.Never improvise by warming blood components in
hot water, in a microwave or on the radiator.

✦
Do not add pharmaceuticals to blood components.

20. ✦
Transfusion of each unit of red cells must be completed
no more than four hours after it has been removed from
controlled 4C storage. Red cell units that have been out
of refrigeration and have not been transfused within four
hours must be returned to the blood bank.

✦
Change the administration set at least every 12 hours for
a continuing transfusion and on completion of the
transfusion.

✦
Discard the empty blood bags according to your hospital
policy.

22. Introduction
Module 12: Transfusion Reactions and
Adverse Events
Many of the serious adverse events that occur as a result of blood transfusion are
unpredictable. The most important are:
Acute haemolytic
transfusion reactions
Infusion of a bacterially
contaminated unit
Transfusion-related
acute lung injury (TRALI)
Severe allergic reaction
or anaphylaxis
Post-transfusion
purpura (PTP)
Transfusion-associated
Graft-versus-host
disease
It is often difficult to distinguish which type of reaction is taking place as the signs and
symptoms of these reactions are very similar. These are detailed on the next slide.
Expert medical help should be sought from a haematologist and/or microbiologist if a
transfusion reaction is suspected. It is often necessary to treat all possible causes.
West Midlands

23. Module 12: Transfusion Reactions and
Adverse Events
Signs & Symptoms to look out for if a patient is having a
transfusion reaction:
Acute reactions are rare but any new signs or symptoms, which develop during
a transfusion, may be caused by a transfusion reaction. It is therefore
important to consider a transfusion reaction if there is any deterioration in the patient’s
condition especially during the first 15-20 minutes of transfusion of blood / blood product.
Please note: In the following ‘suggested treatments’ – when returning the unit of blood / blood
component to the hospital blood bank, check if the giving set should also be sent still attached
to the unit
Pyrexia
Tachycardia
Hyper / hypotension
Change in blood
pressure
Haemoglobinuria
Vomiting / diarrhoea
Urticaria
Rigors
Collapse
Chest / back pain
Abdominal pain
Bone / muscle pain
Headache
Restlessness / agitation
Flushing
Nausea
Breathlessness / coughing
Generally feeling unwell
West Midlands

24. Actions to take if a serious acute reaction is suspected
Module 12: Transfusion Reactions and
Adverse Events
Stop the transfusion immediately and keep the IV line open with a slow
infusion of saline (via a new giving set);
Call a doctor to see the patient urgently. It may be necessary to call the crash
team depending on the severity of the reaction; resuscitation may be required.
Re-check the patient’s identity, ensure this corresponds with the unit of blood / blood
Component and re-check all documentation;
Inform the blood bank. Blood and urine samples will be required to investigate
the reaction (blood bank / medical staff will clarify what is required);
Check and record the patient’s temperature, pulse and blood pressure;
Check respiratory rate and respiratory signs – dyspnoea, tachypnoea, wheeze, cyanosis;
Check oxygen saturation and blood gases;
Provide further management depending on the patient’s clinical features.
This may involve transfer to intensive care unit and mechanical ventilatory support.
It is important to document all observations, symptoms, signs, treatments and tests
performed relating to the event.
Transfusion reactions can be fatal
West Midlands

25. Symptoms/Signs of Acute Transfusion Reaction
Fever, chills, tachycardia, hyper or hypotension, collapse, rigors, flushing, urticaria,
bone, muscle, chest and/or abdominal pain, shortness of breath, nausea, generally
feeling unwell, respiratory distress
Stop the transfusion and call a doctor
Measure temperature, pulse, BP, respiratory rate, O
2
saturation
Check the identity of recipient, the details on the unit and compatibility form
Reaction involves mild
fever or urticarial rash
only?
Urticaria
Mild
fever
Mild Allergic reaction
Give Chlorpheniramine 10mg slowly
i.v. and restart the transfusion at a
slower rate and observe more
frequently.
Febrile non-haemolytic
transfusion reaction
If temp rise less than 1.5
o
C, the
observations are stable and the
patient is otherwise well give
Paracetamol.Restart infusion at
slower rate and observe more
frequently
No
Suspected ABO
incompatibility?
Recheck pack and
patient ID
Yes
ABO Incompatibility
Take down unit and giving set.
Return intact to blood bank.
Commence I.V. saline infusion.
Monitor urine output/catheterise.
Maintain urine output at >100
mls/hr. Give frusemide if urine
output falls/absent. Treat any DIC
with appropraite blood
components. Inform Hospital
Transfusion Department
immediately.
No
Severe Allergic
Reaction?
Yes
Severe allergic reaction
Bronchospasm, angioedema,
abdominal pain, hypotension.
Discontinue transfusion.
Return intact to blood bank along with
all other used/unused units. Give
Chlopheniramine 10mg slowly i.v.
Commence O
2
, give salbutamol
nebuliser. If severe hypotension, give
adrenaline 0.5 ml of 1 in 1000 (i.e. 0.5
mg) i.m. Clotted sample to transfusion
laboratory. Saline wash future
components.
No
Continued on next slide
West Midlands
Module 12: Transfusion Reactions and
Adverse Events
Management of severe acute reaction

26. Continued from previous slide
Other Haemolytic
reaction /bacterial
contamination?
Yes
Haemolytic
reaction/bacterial infection
of unit
Take down unit and giving set.
Return intact to blood bank
with all other used/unused
units.
Take blood cultures, repeat
blood group / crossmatch /
FBC, co ag screen,
Biochemistry, urinanalysis.
Monitor urine output.
Commence broad spectrum
antibiotics if suspected
bacterial infection.
Commence oxygen and fluid
support
Seek Haematological advice
No
Acute
dyspnoea/hypotension
Monitor blood gases
Perform CXR, measure
CVP/Pulmonary capillary
pressure
Raised
CVP
Normal
CVP
Fluid Overload
STOP INFUSION
Give oxygen and Frusemide 40-
80 mg i.v.
TRALI
Dyspnoea, chest x ray,
“whiteout”. Discontinue
transfusion. Give 100%
Oxygen. Treat as ARDS –
Ventilate if hypoxia indicates
West Midlands
Module 12: Transfusion Reactions and
Adverse Events
From: ‘Handbook of Transfusion
Medicine 3rd Edition’.
© Crown Copyright material is reproduced with the permission of the Controller of HMSO and Queen’s printer for Scotland.

27. Key Points
Module 12: Transfusion Reactions and
Adverse Events
Remember: Transfusion reactions can be fatal
• Many of the serious adverse events that occur as a result of blood transfusion
are unpredictable.
• It is often difficult to distinguish which type of reaction is taking place as the
signs and symptoms of these reactions are very similar.
• It is often necessary to treat all possible causes.
• If an acute transfusion reaction is suspected, this should be classed as a
medical emergency and prompt action taken.
• If a transfusion reaction is suspected, always check that the correct patient is
receiving the correct unit of blood / blood component.
West Midlands

28. INVESTIGATION OF REACTION
•Immediate sample :

✦
Venous sample 8-10ml (plain tube) ~ antibody/Gp/

✦
2-5 ml (EDTA) ~ FBP

✦
Blood for RP, LFT, DIVC screen

✦
Urine for inspection and hemoglobinuria

✦
Remaining blood & blood bag send to lab
•24hrs sample : same as above
•Complete The “Report of Reaction to Blood or Plasma
Transfusion” form
•Once the investigation of the transfusion adverse event
is complete, fill up the transfusion adverse event form in
duplicate and send to the blood bank. Send also a copy
of this form to the National Blood Centre.