Module 2 Blood Transfusion

Introduction
You will need to be competent in all areas of blood transfusion prior to becoming a PRHO; This module will direct your learning but it is up to you to put the knowledge and skills into practice. The skills should be attempted in a skills centre before being practiced in the clinical setting.

Aims and Objectives

This module is designed to direct your learning around the knowledge and skills associated with blood transfusion By the end of this module students should be Aware of the when, where, why and who of blood transfusion Aware of the steps necessary to order a blood transfusion and the common reasons why this process fails Able to write up a blood transfusion Able to set up a blood transfusion Aware of the common complications of blood transfusion and their treatments Calculate the required drip rate for a unit of blood

Challenging Knowledge - I
For each of the following patients list:(a) If you would transfuse them and (b) How many units you would give them, if any. (c) What other investigations would you order; What further management would you think about
(1) (2) (3) (4) (5) 23 yo asymptomatic, healthy woman with menorrhagia - Hb 8.9 g/dl, MCV 73fl 86 yo asymptomatic man with occasional angina Hb 9.6 g/dl, MCV 104fl 61 yo man with severe gram negative sepsis Hb 7.0 g/dl, MCV 81fl 54 yo woman post hemicolectomy Hb 8.3g/dl, MCV 84fl 73 yo man presenting with acute upper GI bleed; BP 80/60, Pulse 120 thready Hb 8.0 g/dl, MCV 101fl

Patient
23yo female Menorrhagia leading to iron deficiency anemia

Hb (g/dl)
8.9

MCV (fl)
73

Transfusion
No transfusion

Other Treatment
FeSO4 Investigate if severe

86yo male Macrocytic anaemia

61yo male Severe G negative sepsis leading to normocytic anaemia 54yo female Post-operative normocytic anaemia

9.6

104

No transfusion

Investigate for macrocytosis Drugs, Alcohol, Hypothyroidism, Haemolysis

Treat severe sepsis ceftazidine and gentamicin

7.0

81

Transfuse 2 -3 units initially

8.3

84

No transfusion

FeSO4 Re-check Hb to ensure no further drop

73yo male Macrocyosis probably alcohol related with ? Varicael bleed

7.9

101

Transfusion Xmatch 6 units; Resuscitate

Urgent OGD: May also have coagulpathy and thrombocytopaenia

Challenging Knowledge II
Before attempting the skills in this module List the steps you would take In order to cross match a patient for a blood transfusion To set up a blood transfusion List the common complications of a blood transfusion and their treatment.

Blood and Blood Product Transfusion

You should be familiar with each of these blood products. What are their indications and the complications associated with them?

Whole Blood Packed Cells Platelets Fresh Frozen Plasma (FFP) Cryoprecipitate

The Principle Aims of Blood Transfusion are to:(1) Improve oxygen carrying capacity of blood. (2) Symptomatic improvement. (3) Reduce hypovolaemia. 1 UNIT of Blood should increase the Hb by approx.1g/dL. If no improvement or reduction in Hb think about ongoing blood loss or destruction. You need treat the underlying cause.

Blood Transfusion Indications - I

The Sanguis Study, 1994 No consensus on who, when, where and why to transfuse a patient A lot of variation in practice dependent mainly on the individual clinician ordering the transfusion Strong suggestion that inappropriate use is widespread

Indications for Blood Transfusion

Acute Anaemia (1) Symptomatic hypovolaemia and blood loss. (2) Peri-operative replacing losses (3) Haemolysis (treat the underlying cause) (4) Severe, critical illness.

Blood Transfusion Indications - II

Acute Anaemia
Increase oxygen carrying capacity of blood - Young adults can tolerate 30 40% volume loss with adequate crystalloid replacement alone - Weiskopf et al (1988) Euvolaemic anaemia in healthy volunteers (and patients) down to Hb 5g/dL (!) No demonstrable inadequate tissue oxygenation - I.e. Only for symptomatic hypovolaemia

Keep the Hb 10 g/ dL
(2) Peri -operative
Much quoted by Surgeons still - Keep the Hb 10 g/ dL BUT Carson et al (1988); Stehling & Simon (1994) Patients tolerated Hb 8 10 g/dL No patients died with Hb 8g /dL and 500ml blood loss No data on morbidity ? Healing / recovery etc

Severe illness Expensive Scare

(3) Severe and critical illness
Oxygen delivery is dependent on: (a) Cardiac output (c.o.) (b) Oxygen content of blood However there is very little change in C.O. until Hb 7 g/dL. Herbert et al, 1999 recommended this was the level taken for transfusion in the critically ill unless other factors were present.

Recommendations for Transfusion

Bracey et al, 1999 9 g/dL CABG operation 8 g/ dL Symptomatic anaemia and blood loss 7g/dL Critically ill (Herbert et al) But: on-going and further blood loss must be taken into consideration as must the clinical situation and co-morbidity!

Pale Mrs McPale Hb Unmeasurable

Chronic Anaemia Transfuse according to - Symptoms - Co-morbidities - Level of Activity Correct underlying cause and deficiencies Beware the well patient with the macrocytic anaemia, Hb of 2g/dL Slowly down Slowly up; Remember their blood may be see through but they are essentially euvolaemic. A large, rapid transfusion will cause fluid overload and pulmonary oedema.

Conclusions
Acute Anaemia
Treat Patient according to situation - Co-morbidities - Symptoms - Cause of the Anaemia - Severity and likelihood of re-bleed Red Cell Transfusion SHOULD not be solely used as a plasma expander but primarily as a method to increase oxygen carrying capacity.

Pre Transfusion Considerations

Does the patient need the transfusion? Does the patient want the transfusion? - Verbal consent - ? Soon to be written consent Cross match vs Group and Save? How many units to Cross? (As opposed to many rivers to cross (ho ho)) When to re-cross in active bleeding Local haematology policies

Does the patient need the transfusion?

Yes: Symptomatic anaemia Significant blood loss Anaemia / severe illness Improving Oxygen capacity of the blood No: Asymptomatic Hb 8 g/dL Well patient receiving alternative therapies EPO or Iron Euvolaemic Anaemia secondary to B12 and folate deficiencies

Does the patient want the transfusion?

Consent - Recommended to obtain verbal consent from every patient; ?Soon to be written. Need to discuss: - Indication; Benefits - Risks - Infectious incidence HIV
-

1per 3x 106 HBV 1per2 x 105

Non Infectious e.g. Transfusion reaction - Patients right to refuse transfusion e.g. Jehovahs witnesses, has to be respected if decision made when competent. - Most hospitals now have Blood Transfusion nurse specialist to assist with these issues.

Requesting Blood and Blood Products

Bureaucratic errors are the commonest cause of blood transfusion problems DONT BE A STASTISTIC!
Requests will not (and should not) be processed if any of the following stages are missed or are wrong. (a) Request Form details (b) Blood bottle details (c) No patient wrist band or missed details on the band (If phlebotomist is taking the blood).

Write up the Blood Transfusion Cross match request using the form provided Mrs Kathy Lawrence is a 79yo woman with myelodysplasia. She has been re-admitted with a symptomatic anaemia, Hb 4.9 g/dl, MCV 87. Please write a request form for her cross match using the form provided. Hospital number 213436; DOB 13/09/24; Turner ward; Multiple transfusions over the last 6 months; Blood group A Rh +; No known antibodies; Four pregnancies

Patient Details required apply within

Patient Details required on form Full names DOB Hospital Number Location Blood Group (if known) Previous transfusion and obstetric history Transfusion details Reason for request; Present Hb (if known) Location, Date and Time of expected transfusion Date of request Type of blood (Packed cells, whole blood, G&S only); Number of units. Doctor Details Name, Bleep number and Signature of person requesting the blood

LABELS ARE NEVER ALLOWED ON THE FORMS OR THE BOTTLES

Sample Collection No magazines available

Check patient details on wrist band vs form. Use Pink cross match bottle (In use nationally) Details required on Blood bottle - Full names of patient - DOB; Gender; Hospital number - Signature of person taking blood - Date and Location
Take blood bottle down to the blood bank if required urgently you will also meet the cross match team (essential when you need a favour) and where the blood fridge is situated. PATIENT LABELS WILL NOT BE ACCEPTED!

 Units of blood are stored in the blood bank fridge or theatre fridge. You will need all the patients details prior to going to collect any blood products Check details of blood report form against unit of blood. [Do not accept any wrong or missing details] You will need to sign for the unit in blood bank register; The responsibility is therefore yours! Start transfusion within 30 minutes of blood being removed from the fridge. This picture is for those that have never seen a fridge!

Setting up the Transfusion

The Ian Wright, Wright ,Wright Rule The Right Blood, The Right Patient, The Right Time!
Why cant you use this unit of blood unless you are a Vet?

Cross Match or Group and Save (G&S)

Guides (particularly for major surgical procedures) are available in most hospitals. Most haematology labs can cross match blood in 20 minutes. Cross match when (a) Significant, on-going or potential significant blood loss (b) Severe symptomatic anaemia or illness

Prescribing Blood Transfusion

Please write up the a four unit blood transfusion for Mrs Lawrence using the fluid chart supplied.
The correct format is shown on the next slide. Why do we give frusemide? What is the slowest rate of transfusing a unit of blood?

Ward: Turner Consultant: Feather

Hospital No:213436 Name; Kathy Lawrence

DOB: 13/09/24
Weight
Date Central or peripheral line Type of Infusion Fluid Volume of Infusion Fluid (ml) Drug to be added Total dose in bag Infusion Rate Doctors signature

04.06.04

Blood

1 unit

4 hours

P P

Blood Frusemide

1 unit IV 40mg After second unit

4 hours

P P P

Blood Blood Frusemide

1 unit 1 unit IV 40mg After fourth unit To flush the line

4 hours 4 hours

N. Saline

100ml

20 minutes

Setting up a transfusion
Prescribe Transfusion on IV chart - State units to be given - Rate of each unit (slowest approx 4 hours) - Give saline (100ml+) before (to keep cannula open) and after transfused units to wash through the line. - Frusemide (40mg) is often given with each or every other unit (IV or PO) to stop potential fluid overload. Not required when patient is hypovolaemic - All patient details MUST be correctly charted.

Blood Transfusion
It takes TWO to check details of blood unit Check details on the unit of blood against those written on the form against patients wrist band. ALL MUST BE CORRECT! (Recent advance = bar code devices) DO NOT PUT UP UNITS WHICH YOU ARE NOT HAPPY ABOUT! Check any queries with the laboratory or the haematologist on-call.

Blood Transfusion - Procedure

Introduce yourself to the patient Check patient understanding and ensure they are happy to receive blood transfusion Gain verbal consent Ensure patient has venous access will need to site cannula if no access present! Check equipment Correct unit of blood and blood giving set With a partner check unit of blood details against transfusion slip Check patient details against blood unit. Puts on gloves Attach unit of blood to giving set and run through blood correctly Aseptically attach blood giving set to cannula; Secure the giving set and cannula with bandaging. Ensure blood is flowing and set at correct rate Inform nurses blood is running and to make sure routine observations are made.

Setting up the transfusion

To set up a transfusion (1) Two people to check details (2) Blood transfusion report form; Unit(s) of blood (3) Patient with IV access (!) and wrist id band (4) Sterile blood giving set

Blood Transfusion - Acute Complications I

Complication Acute Intravascular haemolysis Cause ABO incompatibility (Commonest cause is administrative!) Incidence / Likely timing with regard transfusion 1:6x105 Occurs within a few mls of starting transfusion (Mortality 10%) Treatment Shouldnt happen! STOP THE BLOOD! Supportive treatment Treat complications ARF and DIC Unpleasant but not life threatening Paracetamol and cooling.

Febrile Non-haemolytic reactions

Anti Leucocyte Ig or Cytokines in platelet transfusions Commonest in patients receiving multiple transfusions or previously pregnant Transfusion contains plasma proteins or allergens causing an acute IgE mediated allergic response Occurs with plasma and platelet rather than red cell transfusions.

Becoming rarer because of leucocyte depletion in many transfusion practices. Occurs towards the end of or up to hours after transfusion 1 2% of all transfusions Peri-transfusion May occur recurrently

Urticaria

Unpleasant but not life threatening Anti-histamines (can be given prophylactically in known patients)

Infective shock

Bacterial contamination of transfused blood

Rare; 1:5x 105 First 100mls of blood ie early Often fatal! Extremely rare

That of Septicaemia and shock fluids, IV antibiotics

Anaphylaxis

Anti-IgA antibodies ?others Patients are often IgA deficient as well!

Life threatening A.B.C / Crash team call IV / IM adrenaline, steroids, aHistamines, Oxygen Nebulisers.

Blood Transfusion - Acute Complications II

Transfusion Related Acute Lung Injury (TRALI)
RHS Rare; Non-cardiogenic Pulmonary oedema Caused by donor blood containing anti-Leucocyte antibodies Occurs at the start of the transfusion Can be life threatening Treat for (a) Acute transfusion reaction (b) Respiratory failure (ARDS), Shock and Pulmonary oedema

(RHS Rocking Horse Shit Not Royal Horticultural Society) As Dorothy parker once said You can lead a whore to culture but you cant make her think)

Blood Transfusion Delayed Complications

Complication Delayed Red cell haemolysis Cause Recipient IgG vs Red cell antigens Occurs in previously transfused or pregnant patients; Initial cross match will not contain IgG but subsequent cross matches should! Immune mediated donor Tcell reaction (often occurs in immunodeficient patients) Fever, Rash, MOF, Pancytopaenia Anti-Platelet antibodies (usually aHPA-1a) Immune medicated TCP Primarily during pregnancy Incidence / Timing 5 10 days after transfusion <1:500 red cell transfusions Treatment No treatment per se but Patient will receive less benefit from transfusion and once present they will cause problems for future transfusions Usually fatal! Haematology specialist care required In susceptible recipients blood is subjected to Gamma irradiation Use HPA-1a negative red cell and platelet transfusions or LDBlood High dose IV Immunoglobulins for 5 days 0.4g / kg Counselling and specialist advice required

Transfusion associated Graft versus Host disease (TA-GvHD)

Rare 1:750,000 units of cellular blood components transfused 4 30 days after transfusion

Post Transfusion Purpura

RHS Rare 5 -10 days after transfusion Often severe TCP causing bleeding

Post Transfusion Viral Infection

Virus (and other infective agents e.g. prions) undetected by UK screening system Multiple transfusions One unit of blood contains 250mg of iron

HIV <1: 3x 106 HBV and HCV < 1: 2 x 105

Iron overload

Only occurs after several years of blood transfusions e.g. Chronic haemolytic disease

Desferrioxamine increases iron excretion

Generic Management of Acute Transfusion Reaction

Most reactions occur within the first fifteen minutes of blood being started this is the most important time for observations to be done. Do not hide the patient away during this time let the nurses know transfusions are running and that they should do formal observations for the first fifteen minutes and then routinely.

If a reaction occurs: Stop the unit of blood being transfused! Ensure patient is clinically well and no other pathology is present (why are they having transfusion etc) - Treat the underlying cause of reaction; Once patient is deemed OK:Disconnect and take down entire transfusion giving set and blood unit. Maintain venous access with normal saline Check administrative details from transfusion forms and patients wrist band Contact the haematology / transfusion lab and inform them you are returning the unit of blood for testing. Take bloods Blood film, FBC, Cultures, Clotting, Cross match sample (U&Es) If blood transfusion is essential or serious reaction occurs need further advice from haematologist Nursing staff need to observe patient for signs of shock, DIC, acute renal failure Thus Regular observations of BP, Pulse, ToC, Urine output

Re-cap of Multidimensional analysis

Hopefully by now you will be familiar with using multidimensional analysis. I have included the example from module one. If you are confident using other methods this is fine but you must get the answers correct!

Dimensional Analysis
Dimensional analysis is commonly used by chemistry and physics students to ensure they dont make basic calculation errors when using lots of values in an equation with different units; Each time one converts one unit to another we use a conversion factor, which we will call the dimensional analysis conversion factor (DACF) e.g 450g to kg the DACF = 1000g / 1 kg Thus 450g / Xkg = 1000g / 1 Kg XKg = 450g x 1 Kg 1000g = 0.450 Kg Dimensional analysis ensures that both sides of an equation are singing from the same hymn sheet. I.e. The units on both sides are the same. By cancelling the units above and below the line, the units yu are left with on one side should equal those of the value you are seeking. If they dont match, you have mucked up somewhere! It will not ensure your maths is correct.

www.wine1.sb.fsu.edu/chm1045/notes/Intro/Dimanal/Dimanal.htm - Dr Michael Baker a teacher with a similar outlook on education!

Dimensional analysis for party planning If you have ever had a party you have used dimensional analysis. The amount of beer (or soft drinks) and munchies you will need will depend on the number of people you expect. For 30 people you may estimate you need to go and buy 120 bottles of beer and 10 large pizzas (obviously not a medic party!) How did you guestimate these numbers? Heres the dimensional analysis.
4 bottles / person and 1/3 of a pizza per person 30 persons x (4 beers) = 120 beers person 30 persons x (0.333 pizza) = 10 pizzas person But should you buy beer in six packs or cases? 1 case = 4 six packs = 24 Beers 120 beers x 1 six pack x 1case = 5 cases 6 Beers 4 six packs

1 case / 4 six packs = 5 cases / x six packs = 20 six packs

To calculate drip rates / transfusion rates

Blood transfusions are run through specific giving sets with a filter included in the chamber and wide bore tubing. You can NOT run them through a normal giving set as without the filter the blood will coagulate. Likewise you should NOT run fluids such as saline and dextrose through a blood giving set unless it is during or after a blood transfusion.

To calculate drip rates / transfusion rates

For any giving set the tubing will have its own drop factor. This is the number of drops in 1ml. The drop factor is written on the packaging and is dependent on the bore of the tubing. For reasons unbeknown to me the units of drop factor is gtt / minute. Common drop factors are 10, 15 and 20 gtt / min Paediatric drips commonly have a drop factor of 60 gtt /min Saline and Dextrose are commonly run through 10 gtt / min tubing whereas blood is commonly run through 20 gtt / minute tubing

To calculate drip rates / transfusion rates

To calculate the drip rate (drops / minute)
Drip Rate gtt = Volume to be infused (ml) x Drop Factor (gtt/ml) min Time (minutes) 1 unit of blood is approximately 400ml in volume

E.g. A unit of blood is prescribed to run over 2 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min)? (See next slide for answer and calculation) The calculations used here are similar to those used for crystalloid transfusions see module (4)

Example one Calculate the Transfusion rate

E.g. A unit of blood is prescribed to run over 4 hours; The giving set has a drop factor of 20 gtt /ml. What is the drip rate (drops /min) ? Drip rate = 400 ml x 20 gtt ; Drip Rate is drops / minute 4 hour 1ml Thus Drip Rate = 400ml x 20 gtt x 1 hour 4 hour 1 ml 60 minutes By multidimensional analysis units are correct (drops / minute) Drip Rate = 100 / 3 = 33 drops / minute Drop rate is rounded up or down to the nearest drop In the clinical setting to be able to count drops / minute it is sensible to have a number divisable by 4 - Thus you would set this drip at 32 drops per minute

Please try the following calculations They should be included in your folder
(1) A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct?
(2) A 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit?

A 71 yo man is receiving a blood transfusion after a hemicolectomy. The transfusion is set at 30 drops per minute with a giving set of 20 gtt / ml. The unit of blood is prescribed for 4 hours as he has grade 1 heart failure. Is the transfusion rate correct?

Using Drip Rate = Volume to be Infused x Drop factor

Time in minutes

X gtt / min = 400ml x 20 gtt x 1 hour 4 Hr 1 ml 60 minutes The drip should be running at 33 gtt/ min so it needs to be re-set.

A previously well 31 yo woman is having a blood transfusion after having a major upper GI bleed due to a peptic ulcer. The unit of blood is running through a giving set with a drop factor of 10 gtt/ ml. The rate of the infusion is set at 60 drops / minute. How long will it take the 6 units prescribed to run through assuming there is 5 minutes to change each unit?

Using Drip Rate = Volume to be Infused x Drop factor Time in minutes 60 gtt / min = 400 ml x 10 gtt x 1 hour X hour 1 ml 60 minutes X hours = 4000 = 1.11 hours / unit 3600 Thus for 6 units = 1.11 x 6 = 6.67 hours Plus 5 minutes between units 1,2; 2,3; 3;4; 4,5; 5,6 = 25minutes = 0.42 hours Total transfusion (or confusion) = 7.1 hours

Converting drip rate (gtt /min) to ml /hour

In high dependency areas caring for critically ill patients it may be necessary to know the infusion rate in ml/hour this is important in setting infusion pumps and in calculating fluid balance. E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml?

E.g. What is the transfusion rate in ml /hour of a blood transfusion being run at 40 drops / minute through a giving set with drop factor of 20 gtt / ml?
If there are 40 drops in one minute then in 1 hour

40 drops = X drops thus X = 40 x 60 = 2400 drops / hour 1 minute 60 minutes

If the giving set has drop factor of 20 drops/ 1 ml 20 drops = 2400 drops thus Xml = 2400 = 120 ml / hour 1 ml X ml 20

Therefore one could set an infusion pump to deliver this volume or it can be factored into the fluid input /hour.

Calculate the Transfusion rate in ml/hour

A 94 yo woman is receiving a slow blood transfusion for myelodysplasia. The unit of blood is being run at 60 drops / minute through a 20 gtt / ml giving set. Calculate the rate of the transfusion and comment on whether the rate is appropriate

Too Much Too Quickly

If there are 60 drops in one minute then in 1 hour 60 drops = X drops thus X = 30 x 60 = 3600 drops / hour 1 minute 60 minutes
If the giving set has drop factor of 10 drops/ 1 ml 20 drops = 3600 drops thus Xml = 3600 = 180 ml / hour 1 ml X ml 20

Thus the unit of blood (400ml) will run through in 400 / 180 = 2.22 hours
I.e. Too quickly for an 94 yo with myelodysplasia

Learning Outcomes
At this point you should Have read and made notes regarding the who, why, where and when of blood transfusion Be aware of the acute and chronic complications of transfusion Be aware of the steps regarding ordering and setting up a blood transfusion Be able to order a cross match for a patient Be able to prescribe a blood transfusion Be able to calculate the correct infusion rate in drops/min and ml / hour If you are unable to achieve all of these outcomes at this point you will need to continue to practice the skills and re-visit the webpages to refresh your knowledge

Recommended websites and References

www.wine1.sb.fsu.edu/chm1045/notes/Intro/Dimanal/Dimanal.html www.-isu.indstate.edu/nurs/mary/mathprac.html www.classes.kumc.edu/son/nurs420/CalculatingDrugDosages.html www.cs.jcu.edu.au/~michael/web/Sections6.html

References to follow