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Hong Kong Baptist Hospital Blood Transfusion User Guide

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Document Name:

[Blood Transfusion User Guide]

Document Owner: [GM]

Department: [Pathology Laboratory]

Next Review Date: [01.09.2018]

Last Review Date: [01.09.2016]




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HONG KONG BAPTIST HOSPITAL

BLOOD TRANSFUSION USER GUIDE

Prepared by

Pathology Department

Hong Kong Baptist Hospital

Third Edition Sept 2016




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Table of Contents

PREFACE P.4

INTRODUCTION P.5

1. BLOOD SAMPLING, LABELING & ADMINISTRATION P.5

2. REQUEST FOR WHOLE BLOOD / BLOOD COMPONENTS (PACKED CELLS AND BUFFY

COAT)

P.8

3. REQUEST FOR BLOOD COMPONENTS (PLATELET CONCENTRATES, FFP,

CRYOPRECEPITATES)

P.9

4. ABO / Rh(D) COMPATIBILITY & COMPATIBILITY TESTS (FULL CROSSMATCH, TYPE &

SCREEN)

P.9

5. WHOLE BLOOD / BLOOD COMPONENTS: STORAGE AND REQUEST REQUIREMENT,

DOSAGE, ADMINISTRATION AND INDICATIONS

P.10

6. ISSUE OF WHOLE BLOOD / BLOOD COMPONENTS P.20

7. WHOLE BLOOD / BLOOD COMPONENT ISSUE GUIDELINES P.20

8. ISSUE OF UNMATCHED BLOOD P.21

9. TRANSFUSION GUIDELINES TO SPECIAL CLINICAL SITUATIONS P.21

10. RETURN OF ISSUED WHOLE BLOOD OR BLOOD COMPONENTS P.22

11. TYPE & SCREEN OR BLOOD VALIDITY P.22

12. MANAGEMENT AND NOTIFICATION OF ADVERSE TRANSFUSION REACTIONS P.23

13. TRANSFUSION INCIDENT REPORTING P.23

14. AUTOLOGOUS TRANSFUSION (PRE-OPERATIVE BLOOD DEPOSIT) P.24

15. RESIDUAL INFECTIOUS RISK OF HOMOLOGOUS TRANSFUSION P.24

16. ROUTINE SURGICAL BLOOD ORDERING SCHEDULE P.25




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PREFACE

This is the third edition of Blood Transfusion User Guide published by our department. It is my great honor

to have this opportunity to say a few words in the preface. Blood transfusion and blood banking certainly

play an important role in all subspecialties of medicine. Therefore, understanding the basic principle and

essential features of blood transfusion is crucial in providing good and holistic care of all patients. Patient

safety and efficiency of blood transfusion are certainly the traditional core elements in transfusion medicine.

Currently, patient blood management is a multidisciplinary approach to enhance appropriate use of all blood

components. In order to have good utilization of our blood bank service and to achieve the above goals, this

user guide serves as an important guideline to provide update information on most of the practical issues of

blood transfusion.

Special acknowledgement goes to Dr. Mak Yiu Kwong, clinical hematologist, who continuously gives a lot

of invaluable advices and updates to our blood transfusion service and also refines some of the details in our

current transfusion user guide. Moreover, I would like to thank our blood bank staff, especially Ms. Doris

Kwok, our blood bank in-charge, who has put great effort in managing our blood bank and facilitates an

efficient blood transfusion service. I sincerely hope that this user guide is helpful in your daily clinical

practice. Your valuable advices and comments are always welcome.

Dr. Lai Kin Chung Chris

Chairman, Blood Transfusion Committee

Pathology Department

Hong Kong Baptist Hospital




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INTRODUCTION

Blood transfusion involves collecting blood from one person (a donor) and then transfuse to another (a recipient).

Blood transfusion is often needed to replace blood loss in major accidents, during major operations and after childbirth. It may

also be needed to treat other conditions when a patient is anaemic, or suffering for inherited forms of anaemia such as

thalassaemia

Blood transfusion using whole blood is not commonly used in Hong Kong. Instead, whole blood is firstly separated into its three

main components:

Red blood cells,

Plasma, and

Platelet concentrates.

Each component requires specific storage condition and is transfused to patients under different situations. Transfusion therapy

provides the optimal method of transfusing patients who require large amounts of a specific blood component and is associated

with lower risk of having adversed transfusion reactions.

Blood transfusion is a significant medical advancement. The ability to transfer blood components from one person to another has

saved countless lives. It is also a therapy that requires careful preparation and pretreatment testing to minimize the risks and

complications associated with the procedure.

The following information is an overview of blood transfusion, specifically the types of blood transfusions and the methods of

blood typing.

Blood banking, the process of specimen collecting, testing, processing, and storing blood for later use (transfusion), is a

cornerstone of emergency and surgical medicine and is dependent on the clinical laboratory for ensuring the safe use of whole

blood and its components.

1. BLOOD SAMPLING, LABELING & ADMINISTRATION

Blood Sampling

All transfusion recipients should be identified by his/her patient identification information:

A minimum of two patient identification information should be used (e.g. name , hospital number)

The patient should be positively identified by open-ended questions on full name, Hong Kong ID number, date of birth,

hospital number, and etc, from the identification wrist bracelet of the patient should be counter-checked. Never offer a

name and ask the patient if it is correct. If the patient is unconscious or who is incommunicable, this information should

be checked from the identification bracelet of the patient’s wrist or ask the patient’s family member to give

identification of the patient.

The procedure of Handheld Device (Please refer to P.35-P.49, Phlebotomy Manual 2016) have to be followed for

verifying the patient identity and labels printing.




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Labeling the Sample

Preferably 6 ml EDTA blood (not less than 3 ml).

The person who draws and labels the sample should sign on the Lab Order List (or any other request form) and will be

accountable for any sampling errors.

Patient identity should be verified independently by another clinical staff at bedside, and he or she would also sign on

the Lab Order List. This procedure must be carried out before the blood taking.

Before leaving the bedside, the specimen must be labeled with a Handheld Device printed or handwritten label

including patient’s names, Hospital number, and date and time taken.

Any corrections made on the Lab Order List or on the specimen labels should be counter-signed.

For infants aged below 4 months requesting blood for the first time, mother’s blood sample is also required.

(Occasionally, the infant may not be accompanied by his or her mother and the maternal blood sample may not be

available. The infant’s blood should be required for full cross-matching. If the infant’s blood cannot be taken then

select group “O” Rh(D) negative & anti-A/B haemolysin free blood component for the infant.) The maternal blood

sample and the accompanied form should also be properly labeled and signed. The mother’s name, ID number/

Hospital number, baby’s name and Hospital number should be noted on the baby’s Lab Order List. The Lab Order List

and all specimens should be sent to Blood Bank together.

The patient’s blood group, if known, should be entered through the computer request or on the CES for reference.

Cross-check demographic information on the specimen and the Lab Order List.

The blood sampling procedures should be completed as a single event before going to take samples from another

patient.

Blood Bank must not accept a crossmatch request showing discrepancy in the identification description between the

sample label and the Section Test List. Blood Bank staff should not make any corrections for this purpose.

Should there be a subsequent change in patients’ demographic data after computer registration, the ward staff should

cross-check the old and the updated information before the transfusion procedure.

Blood Administration and Monitoring Procedure

1 All whole blood and blood components should be transfused under the instruction of the ordering doctor)

2 Ward staff shall use suitable clean thermal box for whole blood / blood components collection and transportation. All whole

blood / blood components should properly handle to avoid damage and contamination from the environment.

2.1 The thermal box is installed with a timer and should be started counting down from 20 minutes when the ward staff

picks up whole blood / blood components from Blood Bank. The ward staff should take action while it is buzzing.

3 Transfusion should start within 30 minutes of blood issued from Blood Bank and should be completed within 4 hours.

4 Transfusion of platelets or FFP should commence as soon as possible to preserve the maximum viability and activity of the

platelets and coagulation factors respectively.

5 All pre-transfusion checking procedures, include patient identity and the blood component label, must be performed

independently by two qualified ward staff and/ or doctors in front of the recipient before starting transfusion. At least one of

the ward staff should be a registered nurse or of a high rank.

6 Peripheral intravenous access: 18-20G size needles are recommended for adults and 22-24G or smaller needles are

recommended for paediatric patients.




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7 All whole blood and blood components including filtered components must be administered through a standard sterile,

pyrogen-free blood administration set.

8 No drugs should be added to or administered together with the blood or blood components.

9 The administration set should be changed after a maximum of 4 whole blood / packed cell units have been given, or every 12

hours, or when the flow rate becomes inadequate, whichever comes first.

9.1 A separate administration set should be used for platelet conc., and should be started immediately after been issued

from Blood Bank.

10 Always begin platelet transfusion with a new administration set. Transfusion of platelets should be started immediately after

been issued from the Blood Bank and should normally be completed within 30 minutes.

11 Discard administration set once transfusion is completed.

12 Blood warming: Patient receiving blood at a normal rate does not routinely require warmed blood. However, warmed blood

may be necessary in special circumstances such as rapid massive transfusion, exchange transfusion in neonates and severe

cold haemagglutinin disease.

12.1 Blood warming should be accomplished by a blood warmer whereby the blood is warmed to body temperature during

its passage through the transfusion set.

12.2 The blood warmer must be equipped with a visible temperature measuring device and audible warning alarm to alert

the user of malfunctions. It must be operated and maintained according to the manufacturer’s instructions.

12.3 Do not warm blood in water bath or hot water or any uncontrolled heat source. Overheating (>40oC) will cause

haemolysis.

12.4 A unit of blood shall not be attached to a blood warming device for more than four hours.

13 Monitoring of patients during transfusion

13.1 The patient shall be observed for potential adverse reactions during transfusion and for an appropriate time interval

thereafter.

13.2 As a minimum requirement, measure and record the vital signs (BP, pulse rate, and temperature) before the start of

each unit of whole blood / packed cells and at 15 minutes after the start as well as at the end of each whole blood or

packed cells unit.

13.3 For platelet concentrates, fresh frozen plasma and cryoprecipitates transfusion, the transfusion time is usually much

shorter. As a minimum requirement, measure and record the vital signs (BP, pulse rate, and temperature) before

starting, at 15 minutes and at the end of each transfusion episode of a batch of components.

13.4 Start the transfusion slowly (1 ml per minute), and observe for any reaction in the first 10 minutes of the transfusion.

13.5 Provided no adverse reaction occurs, the rate of transfusion can be increased as prescribed.

13.6 The patient should be observed periodically during the transfusion and for an appropriate time period thereafter for

potential adverse reactions.

13.7 Measure the patient’s vital signs when symptoms of a transfusion reaction are suspected. In some circumstances, you

may need to measure the respiratory rate.




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13.8 Advice the patient to report any symptoms and signs of transfusion reaction, e.g. fever, chills, skin rash, shortness of

breath, hypotension, shock, and chest discomfort and back pain.

13.9 Unconscious and paediatric patients require more vigilance when monitoring the signs of transfusion reactions,

14 Discontinue the transfusion in case of any untoward reactions and keep the I.V line patent with saline drip. Report the

incident to the attending physician and Blood Bank immediately.

15 Upon completion of transfusion, the empty or partially transfused blood bags should be kept for a period of 24 hours so that

they would be available for investigation of transfusion reaction if necessary. The blood bags are then disposed according to

infection control policies.

16 There must be a complete record for each unit of whole blood / blood component transfused indicating the recipient’s

identity, blood type, donor unit Whole Blood Number (WBN), date and time of start and finish of transfusion and outcome.

Record the volume transfused according to the reference volume started on the blood bag label.

2. REQUEST FOR WHOLE BLOOD / BLOOD COMPONENTS (PACKED CELLS AND BUFFY

COAT)

Blood samples required for crossmatch: 1 x 6 ml PINK capped plastic bottle or 2 x 3.0 ml PURPLE capped plastic bottle

Blood samples once collected should be sent to Blood Bank as soon as possible.

Blood Bank always keeps a reasonably sufficient stock of packed cells to meet the physicians’ requirement on a

first-come-first-served basis. However, the packed cells stock supply level depends on the stock condition of the Hong

Kong Red Cross Blood Transfusion Service (HKRCBTS).

Other blood components, subjected to the prior arrangement with the HKRCBTS. Those requests should reach Blood Bank

before noon on weekdays and the ward will be informed when they are available. Late requests would cause delay in

transfusion.

These components are:

Buffy coat

Washed red cells

Irradiated whole blood / cellular blood components

Leukocyte depleted (reduced) red cells by filtration

CMV negative blood

Fresh whole blood (less than 5 days old) or Reconstituted whole blood for neonatal exchange transfusion

Mini-packs of red cells from a single donor for neonatal transfusion




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3. REQUEST FOR BLOOD COMPONENTS (PLATELET CONCENTRATES, FFP,

CRYOPRECEPITATES)

Patient’s blood sample for blood grouping is required if his/her blood group is unknown.

FFP, once available, as requested by ward staff, can be thawed (normally takes 30 minutes) and then issued. Once

thawed, FFP is not returnable and should be transfused within 24 hours.

With sufficient laboratory data and clinical information for each individual requisition for platelet concentrates and

cryoprecipitates, Blood Bank will arrange with the HKRCBTS for the required units. Subject to the approval from

the HKRCBTS, Blood Bank will inform the ward for availability of the units.

4. ABO / Rh(D) COMPATIBILITY & COMPATIBILITY TESTS (FULL CROSSMATCH AND

TYPE & SCREEN)

ABO

Compatibility

Donor’s Blood Group

Patient’s Group Whole blood Red cells / Buffy coat FFP Platelet / Cryo-ppt

A A A, O A, AB A, AB, B, O

B B B, O B, AB B, AB, A, O

O O O O, A, B, AB O, A, B, AB

AB AB AB, A, B, O AB AB, A, B, O

Unknown Not recommended O AB AB, A, B, O

For platelet or cryoprecipitates transfusion:

Identical ABO blood group is NOT essential in adults, but avoid units with high titre immune anti-A and /

or anti-B if ABO- compatible units are used.

Infant (< 1 year of age) should receive ABO plasma compatible platelet concentrates and other blood

components.

Patient with documented platelet refractoriness should receive ABO identical platelet if available.

Patient with PNH (Paroxysmal nocturnal haemoglobinuria) should receive ABO identical blood units.

For Rh (D) compatibility, refer to “ Indications” column for Rh (D) negative blood in Section 5. (Whole blood / blood

Components’ storage and request requirement, dosage, administration and indications).




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Full crossmatch

Only the “major” cross-match between the patient’s plasma/serum and the donor red cells is required. The function of

the cross-match is to prevent incompatibility. This is most serious when there is ABO incompatibility. Methods that

demonstrate ABO incompatibility and other clinically significant antibodies should be used.

Type and Screen (T&S) Type and Screen is a procedure in which the patient’s blood sample is tested for ABO, Rh, and clinical significant RBC

antibodies, then stored in the computer database for immediate crossmatch. Particular units are not reserved for

individual patients. If transfusion is required, ABO- and Rh-compatible blood units can be safely released after an

immediate-spin method. However, if the antibody screen is positive, antibody identification and full crossmatch will be

done and compatible blood units will be reserved for that particular patient.

5. WHOLE BLOOD / BLOOD COMPONENTS: STORAGE AND REQUEST REQUIREMENT,

DOSAGE, ADMINISTRATION AND INDICATIONS Generally, all non-urgent components request in the morning, such as Platelet Concentrate, Cryoprecipitate or Leucocyte-

reduced Red Cells etc. would be ready by 15:30 in the afternoon during the weekdays. Once they are ready ward staff will be

informed.




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Blood / components

(storage, approx. vol.)

Request

requirements

Dosage / administration Indications

1

Whole blood / Packed

cells

--Stored at 2-6oC in

monitored refrigerator

--Approx. vol.:

-whole blood:

370-510mL

-packed cells:

220-340mL

--Specimen:

needed for

crossmatch or

Type & Screen

--One standard unit of

whole blood or packed

cells should raise Hb level

by about 1.2g/dL in a

70kg adult.

--Small units are about

70% of large unit. One

small unit should raise Hb

level by about 0.85g/dL

in a 70kg adult.

--For children, 4ml/kg

should raise Hb level by

1g/dL

--Due to the risk of

bacterial proliferation at

room temperature, blood

transfusion must be

started within 30 minutes

of removing the blood

pack from refrigeration

and should normally be

completed within 4 hours.

1. Acute blood loss > 750mL (15% of

blood volume)

Paediatric patient: 10-15mL/kg.

2. Acute blood loss and at least one of the

following:

Loss of > 15% patient blood volume

Hb < 8g/dL

Blood pressure decreases by > 20% or is

< 90 mm Hg systolic

Clinical evidence of inadequate oxygen

carrying capacity.

3. Haemoglobin <8g/dL (haematocrit

>0.24) if not due to a treatable cause.

4. Patient receiving general anaesthesia

Preoperative Hb <8g/dL

Major blood letting operation and with

Hb <10g/dL (haematocrit < 0.3)

5. Cooley’s anaemia or thalassemia major

Notes:

Patients with asymptomatic stable

chronic anaemia, red cell replacement

therapy is not necessary, treat the

underlying cause.




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Blood / components


Request

requirements


2 Fresh whole blood

(≤ 5 days from

donation)

--stored at 2-6oC, in


--Approx. vol.:

370-510mL

--Specimen:

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

--1-2 units

-- Due to the risk of



transfusion must be






1. Neonates with massive blood loss or

requiring exchange transfusion.

(Avoid transfuse RBC in additive)

2. Infant or small child scheduled for open

heart surgery.

3 Reconstituted whole

blood (leukoreduced

red blood cells plus

fresh frozen plasma)



--Specimen:

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

Transfuse within 24 hr of

preparation

1. When the rare phenotype (e.g.,

D-negative) fresh whole blood is not

available for neonatal exchange

transfusion.

4 Mini-pack red cells



--Approx. vol.:

50-100mL

--Specimen:

needed for

crossmatch or

Type & Screen

According to clinical

indication




transfusion must be






Patients less than 4 months of age:

1. Venous Hb <13 g/dL in neonates <24 hrs

old

2. Hb level <13 g/dL and severe pulmonary

disease, cyanotic heart disease or heart

failure

3. Acute blood loss >10% of total blood

volume

4. Removal of blood for laboratory testing

when the cumulative volume removed

exceeds 10% of the infant’s blood

volume within 1 week period and the

circulating Hb level is < 13 g/dL

5. Hb level <8 g/dL in stable new-born




13

Blood / components


Request

requirements


infants with clinical manifestation of

anaemia.

5

Leukocyte reduced red

cells by filtration

(LRBF)

--Stored at 2-6oC in


--Approx.vol: 300 ml

with <0.01X108 WBC

per unit

--Specimen

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

Refer to 1 above




transfusion must be






1. History of > 2 episodes of febrile

non-haemolytic transfusion reaction.

2. Patients requiring chronic or regular

transfusion

3. Haematological disease

6 Rh(D) Negative blood

--Stored at 2-6oC, in


--Approx. vol.:

see 1,2,3,4, above

--Specimen:

needed for

crossmatch or

Type & Screen

Refer to 1 above




transfusion must be






Due to limited supply, RhD negative

blood have to be used in the following

priority:

i. Neonates with HDN caused by anti-D and

D-negative patients with anti-D present

MUST receive D-negative red cells.

ii. D-negative females prior to menopause

SHOULD receive D-negative blood.

iii. Other D-negative patients with no anti-D

and Chinese with unknown D status

MAY receive D-positive blood when

D-negative blood is in short supply.

D-negative females in their reproductive

age, if D-positive platelet concentrates or

FFP were given to them, they should

receive RhIg prophylaxis (250 i.u. for <

18 random donor platelet concentrates or

< 3 singe donor platelet concentrates or

50 i.u. per unit of FFP transfused).




14

Blood / components


Request

requirements


7 Platelets concentrates

--Stored at 20-24oC

with constant agitation

--Approx. vol.:

50mL with >55x109

platelets per unit

** volume of single

donor platelet:

200-240mL with

310x109 platelet per

unit

--Specimen:

needed for blood

group checking

--Require prior

arrangement with

HKRCBTS

--1 unit / 10kg for

bleeding patient

--0.5-0.75 units / 10 kg

for prophylactic use

--1 unit (from 450mL

whole blood) should raise

platelet count by

7-10x109 / L., small unit

(from 350mL whole

blood): about 70% of the

above figure

--1 unit of apheresis

platelet concentrates is

equivalent to one standard

adult dose (for adults up

to 70 kg)

--Document platelet count

within 8 hours before and

at 1 hr after transfusion

for reference is suggested.

--Do not refrigerate,

transfuse immediately,

flush infusion set with

saline after platelet bag

empties

1. Prophylactic administration in patients

with platelet count <20x109 / L if

platelet is not due to accelerated platelet

destruction.

2. Patients with active bleeding or

scheduled for invasive procedure (e.g.

liver biopsy, lumbar puncture) with

platelet count <50X109 /L.

3. Patients undergoing major operative

procedure and their platelet count is

<70x109/ L.

4. Patient with platelet <100 x 109 / L

undergoing retinal or CNS surgery.

5. Patient with platelet < 100 x 109 / L and

active bleeding in post-cardiopulmonary

bypass.

6. Patients undergoing major operative

procedure and their bleeding time is > 13

minutes.

7. Patients massive transfusion with diffuse

microvascular bleeding and inadequate

time to obtain platelet count.

8. Platelet count < 50 x 109/ L for stable

premature neonate or < 100 x 109 / L for

sick premature neonates.

Notes:

Non-emergency platelet transfusion in

ITP, TTP, or HUS requires proper

haematology consultation.




15

Blood / components


Request

requirements


8 Fresh Frozen Plasma

(FFP)

--Stored at

< -30oC in monitored

freezer

--Approx.vol.

(refer to unit’s label)

--Specimen

needed for blood

group checking

--2-4 units of FFP (usual

starting dose is 12-15mL /

kg)

--Document PT / APTT

pre transfusion and post

transfusion within 4 hours

for reference is suggested.

--Maximum of 6 units

thawed at one time

--Transfuse within 24

hours after thawing in

Cytotherm-DR (never

under hot water tap).

Taking care to avoid

contaminating the bag’s

entry ports.

--The validity of FFP is

24 hours (Stored at 2 - 6

oC) after thawing

1. Patient’s PT or APTT >1.5 times mid

reference range with actively bleeding or

invasive procedures contemplated.

2. Patient’s specific factor deficiencies

where treatment with factor concentrates

or cryoprecipitates is not appropriate (i.e.

factors V, VII and XI).

3. Correction of warfarin overdose

inpatients who are bleeding and not

treatable with vitamin K.

4. Treatment of Thrombotic

Thrombocytopenic Purpura (TTP).

5. Management of acute DIC.

6. Clinical coagulopathy associated with:

a. Massive transfusion (> 10 units of

Blood in 24 hrs.):

FFP should be used only IF there is

Documented laboratory evidence of

Coagulopathy or clinical evidence of

diffuse microvascular bleeding.

b. Dilutional coagulopathy:

Patients resuscitated with large amount of

crystalloid/colloid solution usually have

prolonged PT/APTT not associated with

diffuse micro-vascular bleeding. These

patients should receive FFP only if there

is diffuse microvascular bleeding not

caused by thrombocytopenia.

7. Presence of post-operative or

micro-vascular bleeding after

cardiopulmonary bypass, with exclusion

of surgically correctable cause, platelet

dysfunction and residual heparin effect.

8. Hepatic Failure




16

Blood / components


Request

requirements


9 Methylene blue treated

FFP

--Stored at

< -30oC in monitored

freezer

--Approx.vol.

(refer to unit’s label)

--Specimen

needed for blood

group checking

Same with the FFP 1. This component is targeted for clinical

transfusion in paediatric patient group

only.

2. Please note after treatment with

Methylene Blue, the MB PR-treated

plasma is tinted green colour.

3. MB-treated plasma should not be given to

patients with known allergies towards

MB

4. Extra caution should be exercised with

the use of MB PR-treated FFP in a known

G6PD deficient patient.

10 Cryoprecipitates

--Stored at < -30oC in

monitored freezer

--Approx. vol.:

10-30 ml with 80 i.u.

factor VIII and 210 mg

fibrinogen per unit

--Specimen

needed for blood

group checking

--Usual recommended

dose is 10 units

--Document fibrinogen

pre-transfusion and

post-transfusion for the

first indication.


hours after thawing in

Cytotherm-DR. Taking

care to avoid

contaminating the bag’s

entry ports.

--The validity of

cryoprecipitates is 6 hours

(Stored at 2 - 6 oC) after

thawing

1. Documented fibrinogen deficiency (<100

mg/dL) or dysfunction.

2. Haemophilia A if DDAVP or factor

concentrates is not appropriate.

3. Von Willebrand’s disease if DDAVP or

intermediate-purity Factor VIII

concentrates is inappropriate.

4. Uraemia bleeding with prolonged

bleeding time, unresponsive to DDAVP.

5. Factor XIII deficiency.




17

Blood / components


Request

requirements


11 CMV-seronegative

blood components

-stored at temperature

specific for the

components

--approx. vol.: see

specific components

--Specimen:

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

--Refer to relevant

components

1. For premature newborn less than 1 week

old, use fresh CMV negative blood (less

than 7 days old)

2. Low-birth-weight neonates (< 1200g)

born to seronegative mothers (or if the

status unknown).

3. Seronegative recipients of seronegative

donor bone marrow (allogenic BMT).

4. Seronegative recipients of seronegative

solid-organ transplant.

5. Patients severely immuno-deficient or

immuno-suppressed due to disease or

therapy.

Note:

If CMV negative red cells are not

available, use leukocyte-depleted red

cells by filtration to reduce risk of CMV

transmission.

Plasma components, particularly FFP,

have very low risk of CMV transmission.




18

Blood / components


Request

requirements


12 Irradiated blood

components (>25Gy

γirradiation)

--Stored at temperature

for specific

components.

--Specimen:

needed for

crossmatch or

Type & Screen

--Refer to

relevant

components.

-- Require prior

arrangement with

HKRCBTS

--Refer to relevant

components.

--Platelets/granulocytes

should be used with

minimal delay.

--Whole blood/packed

cells should be used

within 24 hr for neonatal

transfusion

--Irradiated whole blood

and packed cells should

be used within 14 days.

For prevention of transfusion-related

graft versus host disease in circumstances

such as:

1. Patients with severely suppressed cellular

immunity.

2. Post-bone marrow transplantation.

3. Foetus requiring intrauterine transfusion.

4. Transfusion from first-degree blood

relatives.

13 Washed red cells

--Stored at 2-6o C in


--Approx. vol.: 200 ml

--Specimen

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

--Transfuse within 12 hr

of preparation




transfusion must be






1. For IgA deficient recipients who may

develop anaphylaxis to transfused plasma

proteins.

2. Patients with PNH (Paroxysmal nocturnal

haemoglobinuria) do not use washed red

cells but use red cells of the same group

as the patient.




19

Blood / components


Request

requirements


14 Buffy coat

(Leucocytes)

--Stored at 20 – 24o C

WITHOUT agitation

--Approx.vol.:

50 ml with 2x109WBC

per unit

--Specimen

needed for

crossmatch or

Type & Screen

--Require prior

arrangement with

HKRCBTS

--Do not refrigerate

--Transfuse immediately

and slowly.


hours of preparation.

--Closely monitor patient

1. For documented severe neutrophil

dysfunction, neutropenia (<0.5×109/L) or

persistent infection not responding to

appropriate antimicrobial drugs.




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6. ISSUE OF WHOLE BLOOD / BLOOD COMPONENTS

Whole blood and blood components are issued when a transfusion is needed.

Check the crossmatch record from the Hospital Information System. A qualified staff brings along with the

Compatibility Report to Blood Bank in the Pathology Department to collect the required units. All the units will

not be re-used to other patients if the units have been taken out of the Blood Bank refrigerator for more than 30

minutes.

Platelet concentrates and buffy coat may be issued for emergency use before bacterial surveillance is completed.

Such unit will be labeled with a special tag. Blood Bank staff will inform the requesting physician for this

situation and send or fax the Blood Component Emergency Release Form to the physician. Physician should

observe the transfusion criteria and prescribe the minimal recommended dose. Recipient should be closely

monitored and all febrile reactions after platelet transfusion should be investigated.

7. WHOLE BLOOD / BLOOD COMPONENT ISSUE GUIDELINES

1. A competent lab staff is responsible for issuing the allocated unit(s) at Blood Bank

2. Cross-check data on Compatibility Report and whole blood / blood component’s label:

(Read aloud please!)

Patient Name

Hospital Number

Patient’s Blood Group

Donor unit’s Blood Group , DIN and Product Code

Donor unit’s expiry date

3. Check any abnormal finding: Clot / Haemolysis / Leakage

4. The Issue Log will be generated by lab staff in the TrakLab System.

5. Cross-check data on Issue Log as above. Do not issue the donor unit if

***WARNING: HOLD DATE IS EXPIRED***

***BLOOD ISSUE IS NOT ALLOWED***

is indicated on the Issue Log

6. Both Blood Bank staff and nursing staff should sign on the Issue Log.

7. Thermal box will be provided when necessary.

8. The thermal box is installed with a timer and should be started counting down from 20 minutes when the

nursing staff picks up whole blood / blood components from Blood Bank.




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8. ISSUE OF UNMATCHED BLOOD

Blood samples for crossmatch should be sent to Blood Bank as soon as possible.

The blood should be drawn into 1 x 6 ml PINK capped plastic bottle or 2 x 3.0 ml PURPLE capped plastic

bottle for blood grouping and antibody screening.

The clinician can ask the nursing staff to collect the blood by signing an authorization request form (Form

number: HPLD(MR)002-P19). A copy of the signed Unmatched Blood Transfusion Record must be sent to

Blood Bank for record.

Four units of group-specific unmatched blood can be issued, within 20 minutes upon receiving the patient’s

blood sample. The clinician will be informed by phone immediately as the issued unmatched unit found

incompatible at any stage of testing. Final Compatibility Report and antibody investigation results will be

released as ready.

Up to 4 units of group-O unmatched blood can be issued for patients with unknown blood group within 10

minutes under desperate situations. Routinely no group-O Rh (D) negative blood kept in hospital Blood Bank.

9. TRANSFUSION GUIDELINES TO SPECIAL CLINICAL SITUATIONS

A) Massive blood transfusion

1. Massive transfusion is arbitrarily defined as transfusion of a volume equivalent to the patient’s total blood

volume within 24 hours or transfusion of more than 6 units of blood (in an adult) within a 6-hour period.

2. The prime objectives are to restore blood volume and secure haemostasis.

3. Packed cells: Refer to Point 8. ISSUE OF UNMATCHED BLOOD, under urgent request for unmatched

but ABO and Rh(D) compatible blood. Always obtain a blood sample before transfusion and complete

pre-transfusion compatibility testing when time permits. It is advisable to use a micro-aggregate filter

and blood warmer when a large volume of blood is transfused within a short period of time.

4. Platelets: Aim to maintain platelet count > 50x 109/L.

5. FFP: Aim to maintain INR < 1.5 and APTT < 1.5 times of control value (i.e. 30 seconds). Allow for 30

minutes thawing time.

6. Cryoprecipitates: Replaces fibrinogen, aiming to maintain fibrinogen level > 100 mg/dL.

B) Autoimmune haemolytic anaemia [Direct Antiglobulin Test (DAT) result positive]

It is impossible to find compatible blood in patients with AIHA, the red cell autoantibodies interfere with

blood grouping, alloantibody detection and compatibility testing, and cause haemolysis of red cells.

1. Clinical indications for blood transfusion for autoimmune haemolytic anaemia include: incipient heart

failure, development of neurological signs, rapidly progressive anaemia and preparation for splenectomy.

Blood transfusion that is not strictly indicated on clinical grounds should be avoided.




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2. The autoantibody may mask the presence of red cell alloantibody which is capable of causing a

haemolytic transfusion reaction.

3. Serological investigations will be referred to Reference Laboratory of Hong Kong Red Cross Blood

Transfusion Service.

4. The strength of the DAT does not predict the severity of disease. For instance, some patients with a

strongly positive DAT may have mild hemolysis, while other patients with a weakly positive DAT may

have extensive hemolysis. Also, the strength of the DAT may not be changed after treatment, even though

the clinical condition greatly improves.

5. For patients with autoantibody that show broad red cell antigen specificity and lack of alloantibody,

transfusion of Rh phenotype-matched blood is preferable. These units are ‘incompatible but considered

suitable for transfusion.’ Patients with presence of alloantibody as well as autoantibody should receive

appropriately selected antigen negative units.

10. RETURN OF ISSUED WHOLE BLOOD OR BLOOD COMPONENTS

Whole Blood and Blood Components are issued only when there is a genuine transfusion needed. Any issued

but unused Whole Blood and Blood Components should be returned to Blood Bank and be avoided to keep in

an uncontrolled temperature storage. Responsible nursing staff should return the unused Whole Blood and

Blood Components to Blood Bank along with the Return of Blood/ Blood Components Form (Form Number:

HPLD(MR)004-N13 ).

Whole blood or Packed cells that have been taken out of the Blood Bank refrigerator for more than 30 minutes,

or that have been warmed to above 10oC or cooled below 1oC should not be re-issued for transfusion.

Platelets that have been stored in refrigerator should not be re-issued for transfusion.

FFP and cryoprecipitates that has been thawed after 24 hours and 6 hours respectively should not be re-issued

for transfusion. The thawed FFP or cryoprecipitate should be kept in 2-6˚ C refrigerator to maintain its upmost

functionality.

11. TYPE & SCREEN OR BLOOD VALIDITY

Routinely, cross-match or Type & Screen test is valid for 3 days unless there is a clear history that the patient

has not been previously transfused within 3 months or the patient is not pregnant. Otherwise, a second blood

sample should be collected for the compatibility testing. This is to reflect the current immunological status of

the patient , as recent transfusion or pregnancy may stimulate the production of alloantibody(ies).

1. Extension of reserved blood units is allowed and should be performed after 3 p.m. on the hold date of

expiry of the reserved blood units.

2. For the best benefit to the patient with negative antibody screen but with history of transfusion /

pregnancy within the past 3 months, a new specimen should be requested after 3 days.

3. If extension of Type & Screen test or blood reservation is required, Blood Bank staff must be informed

and the “Extension of Blood Reservation Request Form” (Form Number: HPLD/006v01/May11) is

necessary.




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12. MANAGEMENT AND NOTIFICATION OF ADVERSE TRANSFUSION

REACTIONS

1. Blood administration procedures should be strictly followed and every patient receiving blood transfusion

shall be monitored closely for development of any transfusion reaction during the entire administration

process.

2. The following signs and symptoms are of concern and can precede or accompany a major, life-threatening

reaction.

Fever Nausea Generalized Bleeding

Chills Flushing Haemoglobinuria / Oliguria

Chest Pain Dyspnoea Back Pain

Hypotension Shock Pain at Infusion Site

3. When symptoms and / or signs of adverse transfusion reactions occur, transfusion shall be withheld and

appropriate management of the patients should be initiated promptly.

3.1 Stop the transfusion immediately.

3.2 Keep IV line open with 0.9% normal saline using new administration set.

3.3 Monitor patient’s vital signs.

3.4 Perform clerical check at bedside immediately to verify the identity of the blood units with that of

the recipient. If there is any discrepancy noted, inform Blood Bank immediately.

3.5 The clinician should be informed immediately for assessment and management of the patient.

3.6 For the benefit to the patient, any minor transfusion reaction should be reported to Blood Bank with

the Transfusion Reaction Investigation Form (HPLD/MR001v02/Sep15).

3.7 For a major transfusion reaction, if the transfusion is discontinued, the residual blood units should be

returned to Blood Bank for appropriate investigations and documentation. Collect appropriate blood

and send to Blood Bank for further investigation if indicated:

Residual donor pack (or the empty bag if transfusion completed)

At least 3 ml EDTA blood (post-transfusion sample)

3.8 All transfusion reactions (major or minor) should be documented in the patient’s medical record and

reported to Blood Bank with Transfusion Reaction Investigation Form. Keep the second copy in the

patient’s medical record.

3.9 Continue to observe and monitor patient.

13. TRANSFUSION INCIDENT REPORTING

All adverse transfusion incidents should be recorded and reported to Blood Bank for registry. Each serious

incident must be reported in the “RiskMan” within 24 hours.




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14. AUTOLOGOUS TRANSFUSION (PRE-OPERATIVE BLOOD DEPOSIT)

Red blood cells can be kept under refrigeration for 21 to 42 days. Patients undergoing elective surgery may

donate blood and reserve it for their own use in the 3 to 5 weeks' period prior to the scheduled operation date.

Arrange with HKRCBTS at least 6 weeks before the scheduled OT. A suitable patient may deposit 2 ~ 5 units

for one’s own use in the 5 weeks preceding surgery. A standard explanation form is available in Blood Bank

for reference.

15. RESIDUAL INFECTIOUS RISK OF HOMOLOGOUS TRANSFUSION

Infectious Agents Residual risk

HIV around 1 in 106

HTLV <1 in 106

HBV 0.5 - 1 in 105

HCV 0.5 - 1 in 105

CMV related complication avoidable if use CMV negative blood

Other virus unknown

Syphilis negligible

Other bacteria contamination rate: 1 in 104

major septic reaction < 1 in 105

Malaria <1 in 105

Other parasites Negligible

Classical CJD and new variant CJD Classical CJD is not considered a risk in blood while

nv CJD could be




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16. ROUTINE SURGICAL BLOOD ORDERING SCHEDULE

(T&S = Type and Screen) (M-T&S = Mandatory Type and Screen)

General Surgery Units required

Adrenalectomy 2

Burst abdomen, Repair T&S

Cholecystectomy & exploration of CBD (open or laparoscopic) T&S

Choledochojejunostomy, sphincteroplasty T&S

Gastrectomy: Partial/Total M-T&S

Gastro-jejunostomy 0

Hepatectomy M-T&S

Ileostomy 0

Laparotomy, no diagnosis 2

Liver abscess, drainage 0

Mastectomy, simple T&S

Oesophagectomy M-T&S

Oesophago-gastrectomy M-T&S

Pancreatectomy: Partial/ Whipple’s Operation M-T&S

Pancreatic pseudocyst drainage 2

Pancreatico-duodenectomy 6

Skin graft T&S

Splenectomy M-T&S

Thyroidectomy (partial & total) T&S

Vagotomy +/- drainage T&S

Vascular Surgery

Aneurysm (Abdominal aortic, infra-renal aortic, peripheral vascular,

ruptured, thoracic / thoracic-abdominal)

M-T&S

Bypass (aorto-femoral, aorto-iliac) M-T&S

Bypass (axillo-femoral, bifemoral, femoro-popliteal) 2

Endarterectomy: Carotid /Femoral M-T&S

Embolectomy T&S

Renal artery graft M-T&S

Shunt V-P / V-A 0

Varicose vein stripping 0

Cardio-Thoracic Surgery




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CABG M-T&S

Bronchoscopy – lung biopsy T&S

Decortication 3

Open pleural / lung biopsy T&S

Mediastinal Tumour Resection M-T&S

Mediastinoscopy T&S

Pleurodesis T&S

Pneumonectomy 3

Thoracotomy / lobectomy M-T&S

Valve Replacement M-T&S

Ventricular Septal Defect M-T&S

Head and Neck

Alveolar bone grafting with iliac crest or chin bone M-T&S

Cleft palate repair T&S

Head and neck reconstruction M-T&S

Glossectomy T&S

Laryngectomy / PLO M-T&S

Maxillectomy M-T&S

Neck dissection M-T&S

Odontogenic tumour, excision M-T&S

Osteotomy of facial bones for facial deformities

- genioplasty

T&S

- maxillar Le Fort osteotomy 4

- ramus osteotomy (sagital split or vertical subsigmoid osteotomy) 2

- segmental osteotomy (Wunderer, Schuchart or Hofer Osteotomy) 2

Parotidectomy T&S

Pharyngectomy 2

Reduction & fixation of facial bones fracture

(zygoma, maxilla and/or mandible)

T&S

Temporomandibular joint surgery T&S

Neurosurgery

Craniectomy M-T&S

Burr Hole M-T&S

Transphenoidal Operation M-T&S




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Cervical Spine Surgery M-T&S

Paediatric Surgery

Cleft lip palate T&S

Hirschsprungs disease T&S

Hypospaddias reconstruction T&S

Intussusception T&S

Urology

Total Cystectomy + Urinary Diversion M-T&S

Cystoplasty M-T&S

Cystectomy & urethrectomy M-T&S

Cystolithotomy 0

Cystotomy 0

Hydrocele 0

Nephrectomy, Open M-T&S

Lithopaxy 0

Nephrolithomy, Open M-T&S

Nephrolithomy, percutaneous T&S

Optical urethrotomy 0

Orchidectomy 0

Prostatectomy: Open T&S

Prostatectomy: TURP T&S

Pyelolithotomy T&S

Pyeloplasty T&S

Radical Prostatectomy M-T&S

Renal transplantation 2

Renal transplantation, graft nephrectomy T&S

Renal transplantation, donor nephrectomy T&S

TUR bladder tumour T&S

Ureteral reimplantation or repair 2

Ureterolithotomy T&S

Urethroplasty 2

All maternity cases M-T&S

Gynaecological Surgery




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Wertheim’s Operation M-T&S

Radical Hysterectomy + Staging M-T&S

Myomectomy T&S

Spine Operation

Laminectomy: Single level T&S

Multiple level + fusion 2

Spinal Fusion: Anterior/Posterior M-T&S

Hip Operation

THR M-T&S

AMA T&S

Cemented Thompson T&S

DHS T&S

Revision THR 4

Knee Operation

TKR M-T&S

Synovectomy T&S

Fusion T&S

Amputations

Above knee T&S

Below knee T&S

Micro-Reconstruction

Free flap 2

Vascularized bone graft 2

Replantation (digit, single) T&S

Brachial plexus repair (without vascular complication) 2

Trauma

Femoral fracture: AO Nail T&S

DHS / gamma nail T&S

Condylar T&S

AO screw T&S

Compound fractures 2

Tibial fractures: AOnail T&S

Pilon fracture T&S

Plateau fracture T&S

Open fracture 2

Complicated Fracture M-T&S

Pelvis & Acetabulum 4

Humeral fractures

Proximal T&S

Shaft T&S

Colo-Rectal Surgery




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Anterior resection 2

Bowel resection: abdominal perineal 3

Colon resection 2

Colostomy 0

Colostomy closure 0

Haemorrhoidectomy 0

Rectum-pouch: resection / excision, etc. T&S

Rectopexy T&S

Investigative or biopsy

Procedures Units required

Cardiac catheterization +/- angioplasty T&S

Liver biopsy T&S

Renal biopsy T&S

Blood Bank Telephone: 2339 8929

Blood Bank Fax: 2339 8934

REFERENCES

American Association of Blood Bank Technical Manual. 17th edition

Transfusion Guideline for HA Hospitals 2013

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