Blood Transfusion

Dr William Dooley

Plan

• Cases

• Blood groups / Indications

• Procedure

• Monitoring / Reactions

CasesFor following cases: - Would you give them a blood transfusion? - How many units you would prescribe? - What other investigations/management would you consider?

1. 23 yo asymptomatic, healthy woman with menorrhagiaHb 84 g/l, MCV 73fl

2. 86 yo asymptomatic man with occasional anginaHb 96 g/l, MCV 104fl

3. 73 yo man presenting with acute upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/dl, MCV 101fl

Cases1. 23 yo asymptomatic, healthy woman with menorrhagia

Hb 84 g/l, MCV 73flMicrocytic anaemia Iron deficiencyMx: Oral iron replacement

(e.g. Ferrous Sulphate 200mg TDS)No tranfusionIx: If severe

2. 86 yo asymptomatic man with occasional anginaHb 96 g/l, MCV 104fl

Macrocytic anaemia Mx: Treat causeIx: ?cause: alcohol, meds, hypothyroidism, haemolysis

3. 73 yo man presenting with acute/severe upper GI bleed BP 80/60, Pulse 120 thready. Hb 82 g/l, MCV 101fl

Acute anaemia Mx: Cross Match and transfuse 4-6 unitsUrgent OGDIx: FBC / Coagulation

Cases

Indications for Blood Transfusion

Acute Anaemia (rarely chronic anaemia)Symptomatic anaemia and blood loss.Peri-operative: ‘replacing losses’Haemolysis (treat underlying cause)

Case-case basisCo-morbidities SymptomsCausePatient choice

Threshold of Hb?Transfusion should be considered if Hb below 80 g/LIf the Hb is below 70 g/L transfusion is usually indicated

Blood products

Packed Red CellsCommonly used to correct anaemia and acute blood loss1 unit raise haemoglobin by ~10-15g/l in 70kg patient

Platelets For severe thrombocytopenia; consider if patient still actively bleeding1 unit raise platelets by 20x109

Same bedside checks and ABO/RhD checks as with red cells

Fresh Frozen Plasma (FFP)Contains all the coagulation factors. Indicated in clotting defects

e.g. Disseminated Intracellular Coagulopathy

Whole blood Rarely used – components more valuable

Blood GroupsUNIVERSAL

DONORUNIVERSAL RECIPIENT

UK

Frequency42% 8% 3% 47%

33 yo woman with menorrhagia, complaining of lethargy, palpitations and dizziness.

Obs: HR 110 BP 125/89 RR 16

FBC: Hb 54 g/l, MCV 73fl

1. Discuss options for management with the patient and gain valid informed

consent patient for blood transfusion.

2. Prescribe the blood products

3. What pre-transfusion checks are required

4. Set up the transfusion

5. What monitoring is required during the transfusion

OSCE Scenario

1. The following information should be discussed:

• Type of blood / blood component

• Indication for transfusion

• Benefits of the transfusion

• Risks of transfusion

• Possible alternatives to transfusion

• How the transfusion is administered and the importance of correct

patient identification

• Inform patient that following a blood transfusion they can no longer be

a blood donor.

2. Provide written information.

3. Check if patient needs time to consider or requires further information.

4. Document the discussion in the patient’s clinical records.

Transfusion discussion

Prescribing Blood

Different at different Trusts – but principles the same

Usually on separate blood transfusion chart, prescribe:

“Packed Red Cells”

Timing: Needs to be complete in 4 hours (so logistically usually over 1-3 hours)

Same prescribing principles as with normal meds: sign/print name, date, time

Blood sample

Positive ID check- surname/forename/DOBConfirm with ID wrist band and request formGroup and Save vs Cross Match

Write details on blood bottle after blood addedPt ID (name/DOB/hospital number), patient location, date/time

of sample, signature of person taking blood

Pre Transfusion Checks – what to check

Ask patient full name and DOB (positive ID check) at bedside

TWO STAFF; Check this against their wristband (patient must be wearing)Check details (plus hosp no.) against compatibility label / request formConfirm prescription chart completed

Check blood unit label expiry date / number and blood groupCheck the blood bag – ensure free from clots / leaksRecord- blood pack number, date/time and signature of both staffSend request label back to lab to monitor completion

Pre Transfusion Checks – how to check

Putting up the blood

Aseptic technique – wash hands, gloves, apronCheck expiry of (double lumen) giving set

Connect the giving set to the blood bagSqueeze blood into both chambersPrime the giving set with blood

Attach to cannulaSet drip rate Document

When should observations be checked?Initial/baseline observations15 minutes after startingHourly thereafterAt end of transfusion

What should you be checking for? TemperatureHR/BPRR/Sats

What symptoms should you be advising the patient to report?Chest/Abdo painSOBRestlessness/anxietyRashBlood in urine

During procedure checks

When to stop the transfusion

Temperature - Increase by 1 degree

Blood Pressure - Significant change (+/- 10mmHg)

Heart Rate - Significant rise

New OSCE Scenario

74 year-old female with GI bleed

Transfused1 unit Platelets & 4 units RBCs

During transfusion– Difficulty breathing– Hypoxia– Increased respiratory rate

Complications – which one?

Acute haemolytic reaction

TRALI

Infections

Anaphylaxis

Iron overload

Allergic rxn

Post-transfusion purpura

Fluid overload

Bacterial contamination

Graft vs host disease

Non-haemolytic febrile transfusion rxn

Transfusion Reactions

Early vs Late

General management principles:Stop transfusion Maintain line with IV FluidSend blood product to labNew FBC/U+E/Clotting samplesCall for helpDocument and report symptomsThink specifics for management

Early vs. Delayed complications

Early (<24hrs)

Acute haemolytic reactionAnaphylaxisBacterial contaminationTRALI / TACONon-haemolytic febrile

transfusion rxnAllergic rxn

Late (>24hrs)

InfectionsIron overloadGraft vs host diseasePost-transfusion purpura

Early: Acute haemolytic reaction

e.g. ABO incompatibility – commonly clerical errors

Signs/symptoms:agitation, rapid onset fever, hypotension, flusing,

abdominal/chest pain, DIC +/- deathManagement: STOP TRANSFUSIONCheck blood and patient detailsSend unit of blood back to labUrgent FBC, Clotting, U+E, cultures and urine IV Fluids

LARGELY PREVENTABLECOMMONEST CAUSE = HUMAN ERROR

Acute Lung Complications: TRALI vs. TACO

Signs/symptoms

Transfusion Related Acute Lung Injury

Dysponea, cough

STOP Transfusion

Give high-flow oxygen

Treat as ARDS

Transfusion Associated Circulatory Overload

Dysponea, hypoxia, tachycardia, creps+/- echo/BNP

STOP TransfusionHigh flow oxygen Diuretic (furosemide)

Management

Acute: Other reactions

Non-haemolytic febrile transfusion reactionShivering and fever (1-1.5hrs post starting)Unpleasant but not life threatening

Rx- SLOW / STOP Transfusion. Give anti-pyretic (paracetamol)

Bacterial ContaminationFever, hypotension and rigors

Rx- STOP transfusion, Urgent septic screen, Broad spec ABx

AnaphylaxisBronchospasm, cyanosis, hypotension, soft tissue swellingRx Slow/stop transfusion. Maintain airway + Oxygen. Call

Anaesthetist

Allergic reactionUrticaria and itchRx with Chlorphenamine

Chronic: Infections

Risk of HIV per unit transfused = 1 in 6 millionRisk of Hep B per unit transfused = 1 in 1.3 millionRisk of Hep C per unit transfused = 1 in 28 million

All tested for Hep B / Hep C / HIV 1&2 / Human T-cell lymphotropicvirus / syphilis +/- CMV and malaria

Risk = asymptomatic window period

Chronic: Other

Post Transfusion Purpura5-7 days post transfusionPlatelets fall – can be lethal

Graft-versus-host diseaseRare. Fatal.Donor lympocytes mount an immune response against the immunocompromised hostPrevented by irradiation of donor blood

‘the life of all flesh is the blood thereof: whoever eat it shall be cut off’ (Lev. 17:10–16) ‘abstain from the meats offered to idols and from blood’ (Acts 15:28–29) (1–3).

Is blood transfusion necessary?

If so, ensure:

Right blood

Right patient

Right time

Right place

Gained valid and informed consent

Documented

Monitor

Summary

ANY QUESTIONS???