PRINCIPLES OF TRANSFUSION

• Blood components are derived from volunteer whole blood UK donors
• e.g. red cells, platelets, fresh frozen plasma (FFP), cryoprecipitate and granulocytes
• Blood products are medicinal products manufactured from non-UK sourced pooled plasma
• e.g. Octaplas^®, fibrinogen concentrate, IV immunoglobulin, albumin
• Contact numbers of transfusion team

Hazards

• Undertake Blood transfusion only when the benefits to the patient outweigh the risks
• Most adverse events are the result of administrative and clerical errors
• Transfusion of ABO-incompatible blood is potentially fatal and occurs as a result of human error(s) in sampling/patient identification
• ABO incompatible transfusion is a Department of Health ‘never event’
• National audits in England consistently show inappropriate use of all blood components; 15–20% of red cells and 20–30% of platelets/plasma
• Recipients of any blood components (or products) cannot be blood donors as risk vCJD
• Use alternatives to transfusion wherever possible

• Patient Blood Management (PBM) is a multidisciplinary approach to providing individualised, evidence-based transfusion practice for patients who may need a blood transfusion
• Clinical management of anaemia/thrombocytopaenia/deranged clotting depends on the underlying cause and clinical situation
• PBM minimises inappropriate and/or avoidable transfusion, supports best patient outcomes and allocation of finite NHS resources
• The ‘3-pillars’ of PBM can be summarised as:
• Maximise erythropoiesis – identify, investigate and treat anaemia
• Reduce bleeding – anticoagulant management, surgical techniques, therapeutic agents
• Optimise tolerance of anaemia – oxygenation, disease management, restrictive transfusion thresholds

• Anaemia is defined by WHO as Hb <130 g/L in men and Hb <120 g/L in non-pregnant women
• Identify and investigate all anaemic patienets. See Chronic Anaemia guideline
• Treat the causes of anaemia e.g. haematinic replacement

Decision to transfuse

• Base decision to transfuse on the whole clinical picture
• cause of the abnormal results
• current and historic laboratory parameters
• symptom severity
• underlying co-morbidities
• clinical situation
• bleeding risk of any procedure
• risk of adverse event
• patient choice
• Transfusion decisions may be made by a doctor, or a non-medical prescriber who has undertaken additional relevant training and competency assessment 

Risk assessment

• Always assess and document severity of anaemia symptoms and/or bleeding
• Before and after every unit transfused, assess for transfusion associated circulatory overload (TACO)

Anaemia severity grading score

Modified World Health Organisation bleeding score

• In the absence of active bleeding, use the minimum number of units required to achieve a target Hb threshold and improve symptoms
• Each unit transfused is a treatment decision – i.e. 1-unit RBC, 1 ATD platelets

Assessment after each unit transfused

Clinical

• Have the symptoms/signs of anaemia (or thrombocytopaenia) resolved?
• grade anaemia symptom severity especially if transfusing above recognised Hb thresholds
• Is there evidence of fluid overload (TACO)?

FBC

• Check Hb/platelet increment after each unit transfused
• except in active bleeding, chronically transfused outpatients or where target threshold cannot realistically be achieved
• FBC can be performed at 15 min post transfusion (or consider blood gas for Hb check)

• In the non-emergency setting, blood components will only be issued when a patient’s blood group has been confirmed via 2 independent samples e.g. an historic record
• Most recent G&S result will state if a second sample is required before the issue of blood components
• the need for a second G&S will not delay the processing of a crossmatch sample
• obtain second sample at a different time point using positive patient identification (PPID) at all stages

• Obtain valid consent for blood transfusion and document in the clinical record before transfusion
• Consent should include:
• indication for transfusion
• benefits e.g. symptom relief of heart failure/angina
• risks including acute transfusion reactions, human error, fluid overload and delayed transfusion reactions (including antibody formation and transfusion related infections e.g. bacterial, viral, other)
• alternative treatments available e.g. iron supplementation
• that patient can no longer be a blood donor
• If patient is unconscious or unable to receive this information, obtain consent retrospectively/from patient’s legal guardian
• Use consent stickers for each transfusion episode (comes with first unit)
• At discharge, include in the discharge summary transfusion decisions, outcomes and adverse events
• Give patient information leaflets (PILs) to patients before transfusion or retrospectively where not possible

Jehovah’s witnesses

• Jehovah's witnesses do not accept blood components (may accept blood products)
• Transfusion without consent is a gross physical violation
• Discuss consequences of not transfusing
• Record discussion in the medical notes and include a copy of the signed advanced decision document
• Use ‘No blood’ logo wristband
• For further advice, contact the JW hospital liaison committee 

• Complete request form fully and legibly
• use full (accurate) patient identifiers including NHS number
• always indicate the urgency of your request
• person obtaining sample must sign the request form
• Telephone requests can be made to:
• convert a G&S into a crossmatch (where valid G&S available)
• order non red cell blood components

Compatibility testing

• Must represent patient’s current immune status
• Transfused or pregnant within 3 days to 3 months
• only if taken less than 72 hr before transfusion, valid G&S
• Transfused or pregnant >3 months
• only if taken less than 1 week before transfusion, valid G&S
• Chronically transfused patients with no allo-antibodies
• timings of G&S validity may differ

Blood sampling for transfusion

• Patient wears an approved wristband with full patient identifiers
• Carry out positive patient identification (PPID)
• ask patient to state their full name and date of birth
• check details given verbally by the patient match those on the wristband
• check details on wristband identically match those on request form
• Take blood: 6 mL pink EDTA tube
• Fully label the sample bottle at the bedside against the wristband (no stickers allowed)
• person who has obtained the sample must label and sign the sample
• illegible, misspelt or incorrect samples will be rejected by the laboratory
• Send G&S or crossmatch sample to lab with corresponding fully completed request form

Unknown patients

• Minimal acceptable sample labelling comprises:
• temporary unique hospital number
• sex
• estimated date of birth (to show if special blood requirements indicated)
• Once unknown patient has been identified, new transfusion samples will be required

Emergency transfusion

• Take crossmatch sample before administration of any blood components
• In the emergency setting, ABO specific blood will be issued in the absence of a confirmed blood group
• i.e. the ‘Two-sample rule’ does not apply in the emergency setting

• Only doctors or non-medical prescribers who have undergone additional training competency assessment can prescribe blood components/products
• Prescribe blood components on the fluid prescription of the drug chart

Prescription includes

• Core patient identifiers (full name, date of birth, NHS number)
• Component type e.g. red cells, platelets
• Volume e.g. 1 unit, 1 ATD
• Specified rate (min) e.g. 120 min – depends on indications and risk of fluid overload/TACO
• Special blood requirements (SBR)
• e.g. irradiated, HbS neg, Rh matched, ‘no special blood requirements’ (latter is just as important)
• Additional medications e.g. diuretics
• It is the prescriber’s responsibility to share information on SBR with the transfusion laboratory

• Only assessed staff can collect blood components
• Check availability and location of blood components
• Receiving doctor/registered practitioner must check correct component has been delivered, signing with date/time received
• Transport blood components in designated transport bags or validated transport boxes where indicated, available from transfusion laboratory

Storage

• Each blood component is stored under ‘optimal’ conditions. See individual guidelines for details
• Cryoprecipitate, Fresh Frozen Plasma, Platelet Transfusion, Red Blood Cell Transfusion
• Store red cells in designated blood refrigerators only
• do not refrigerate platelets or cryoprecipitate
• Administer components as soon as possible after receipt
• If unable to transfuse, return units to transfusion laboratory asap (within 30 min of leaving cold storage) so product can be safely re-issued to another patient
• Transfer boxes/disposable transport bags are validated for transport not for storage

• Complete transfusion within a maximum of 4 hr from leaving controlled storage
• Blood components are medicines
• administered by a medical officer, registered nurse, registered sick children’s nurse or registered midwife
• student nurses and trainee ODPs can be involved in the checking and administration of blood components under the direct supervision of a registered practitioner and must have their signatures countersigned
• Perfusionists may connect blood as directed by the anaesthetist who will take overall responsibility for the checking and administration of blood components
• Transfusions at night may proceed where there is:
• a clear clinical indication
• sufficient staffing levels to allow for safe monitoring of the patient
• the patient’s wishes have been considered

Bedside checks

• Registered practitioners must undertake two independent bedside checks
• Carry out positive patient ID (PPID)
• ask patient to state his/her full name and date of birth and check these details match those on the patient’s wristband
• check details on patient’s wristband (including NHS number) match full details on the prescription chart and the compatibility label (attached to unit)
• Check unique donation number and blood group on compatibility label matches that on unit
• Check unit complies with any special requirements on the prescription e.g. irradiated
• Check quality of blood component
• inspect for leaks, discolouration and/or clots
• check expiry date (to midnight on date of expiry)
• Record start/finish time/date on the compatibility form or ‘pink slip’
• this does not form part of the checking process
• If any discrepancies found, do not transfuse

Infusion

• Always use a standard blood transfusion giving set with 170–200 micron integral filter
• Routinely change giving set every 12 hr or 3 units
• sooner if delay between units anticipated
• use a new giving set for platelets to avoid platelet clumping
• Use an electronic infusion pump where available
• Specify administration times
• Any blood component connected to patient’s IV access is regarded as ‘transfused’ for traceability purposes, even if unit was subsequently (partially) wasted
• Use Pack-label stickers on the prescription chart to aid traceability

Blood warmer

• If clinically significant cold antibodies
• As soon as possible after activation of the major haemorrhage protocol (MHP)
• In all patients undergoing elective or emergency surgery requiring ≥500 mL fluids including blood components

• Explain procedure
• advise patient to report any symptoms of possible acute transfusion reactions
• Routine transfusion observations (temperature, pulse, BP, respiratory rate, oxygen saturations):
• <60 min pre-transfusion
• at 10–15 min
• <60 min of unit completion
• Perform observations more often where:
• patient is unconscious
• unable to report adverse events
• at high risk of TACO
• if an acute transfusion reaction is suspected
• Maintain a fluid balance chart
• Monitor IV access
• Observe patient throughout transfusion for early recognition of potential transfusion related adverse events

• It is a legal requirement to maintain a record of the fate of each donated unit for 30 years
• requires 100% compliance
• Compatibility form (or ‘pink slip’) and prescription chart
• record date/time of commencement (and completion) of each unit
• both signatures of the doctor/registered practitioner who administered/checked unit
• unique donation number stickers are provided on pack label
• Record on availability and location system
• Medical notes
• evaluate patient after each unit (clinically and laboratory results)
• document outcome of transfusion and any adverse events
• include in discharge summary