Dr. Salwa Hindawi

Blood Transfusion Guidelines in Clinical Practice

Salwa HindawiMSc, FRCPath, CTM

Medical Director of Blood Transfusion ServicesKAUH

26th July2008

Dr. Salwa Hindawi

Introduction

Blood Transfusion is not without hazards

you should weigh the risk against benefit

use of right products to the right patient at the right time

Dr. Salwa Hindawi

The risks associated with transfusion can be reduced by: - Effective blood donor selection.- Screening for TTI in the blood donor population. high quality blood grouping, compatibility testing. - Component separation and storage.

- Appropriate clinical use of blood and blood products. - Quality assurance

Donor Patient

Dr. Salwa Hindawi

Whole blood

Plateletsrich

plasma

1stcentrifugation

Platelets

concentrateWhole bloodWhole blood

2nd centrifugation

Fresh plasma

FFP for clinical use

FFP for fractionation

Optimal additive solution

Red cells in OAS

Cryoprecipitate

RedCell

concentrate

Dr. Salwa Hindawi

Patient ABO Type RBCs, Platelets Plasma &  Cryoprecipitate

O O O, A, B, AB

AA,OA,AB

BB,OB,AB

ABAB,A,B,OAB

ABO Selection of Blood Components

Dr. Salwa Hindawi

Principles of Clinical Transfusion Practices

Avoid blood transfusion Transfusion is only one part of the

patient’s management. Prevention and early diagnosis and

treatment of Anemia & underlying condition

Use of alternative to transfusion.eg. IV fluids

Good anesthetic and surgical management to minimized blood loss.

Dr. Salwa Hindawi

– Prescribing should be based on Prescribing should be based on national guidelines on the clinical use national guidelines on the clinical use of of blood taking individual patient blood taking individual patient needs into needs into account.account.

– Hb level should not be the sole Hb level should not be the sole deciding Factor Clinical evaluation is deciding Factor Clinical evaluation is importantimportant

Dr. Salwa Hindawi

– Consent form to be obtained from the patient before transfusion.

– The clinician should record the reason for transfusion clearly.

– A trained person should monitor the transfused patient and if any adverse effects occur respond immediately.

Dr. Salwa Hindawi

Informed consent

• Patient should be informed that transfusion of blood or blood component is a possible element of the planned medical or surgical intervention

• patient should be informed about the risks, benefits and available alternative

• Consent form is a doctor responsibility

Dr. Salwa Hindawi

• WHEN WE SHOULD TRANSFUSE BLOOD ?&

WHAT BLOOD COMPONENT

SHOULD BE TRANSFUSED ?

Dr. Salwa Hindawi

TO TRANSFUSE BLOOD TO TRANSFUSE BLOOD

WHEN WHEN

NECESSARYNECESSARY

Dr. Salwa Hindawi

• The lowest threshold for transfusion of components are:

• Hb level of 6-7g/dl. • FFP threshold PT & PTT 1.5 times the

upper limit of the normal range. • Platelet threshold of: 10 000/µl- 20 000/µl for prophylactic

transfusion. Consider: Clinical judgment

Triggers of Component Triggers of Component TransfusionTransfusion

Dr. Salwa Hindawi

Invasive or surgical procedures:

• 20 000/µl for BMA and Biopsy

• 50 000/µl for surgery, massive transfusion, Liver cirrhosis.

100 000/µl for surgery to brain or eye.

American Society of clinical Oncology guidline,1996&2001.American Society of clinical Oncology guidline,1996&2001.

Williamson LM. Transfusion Trigger in the UK. Vox sang Williamson LM. Transfusion Trigger in the UK. Vox sang 2002.2002.

AABB Technical Manual 14AABB Technical Manual 14thth ed, 2002. ed, 2002.

Dr. Salwa Hindawi

Administration of blood components

Pretransfusion:

Recipient identification: The name and identification number on the patient’s identification band must be identical with the name and number attached to

the unit .

Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit (if not the same as the

latter) must agree.

Dr. Salwa Hindawi

Haemoglobin (Hb) trigger for transfusion

Indications NB: Hb should not be the sole deciding factor for transfusion.

< 7 g/dL

If there are signs or symptoms of impaired oxygen transport

Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available e.g. sickle cell disease or iron deficiency anemia

< 7 – 8 g/dLPreoperative and for surgery associated with major blood loss.

< 9 g/dL

In a patient on chronic transfusion regimen or during marrow suppressive therapy.May be appropriate to control anaemia-related symptoms.

< 10 g/dLNot likely to be appropriate unless there are specific indications. Acute blood loss >30-40% of total blood volume.

Guidelines for blood component therapy

Dr. Salwa Hindawi

Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age:

1 .Hemoglobin <7 g/dL with low reticulocyte count and symptoms of anemia

2 .Hemoglobin <10 g/dL with an infant

On <35% hood O2

On O2 by nasal cannulaOn continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H2OSignificant apnea or bradycardiaSignificant tachycardia or tachypneaLow weight gain

3 .Hemoglobin <12 g/dL with an infant

On >35% hood O2

On CPAP/IMV with mean airway pressure 6 to 8 cm H2O

4 .Hemoglobin <15 g/dL with an infant

On extracorporeal membrane oxygenation (ECMO)Congenital cyanotic heart disease

Dr. Salwa Hindawi

Platelet Count trigger for transfusion

Indications

< 10 x 109/LAs prophylaxis in bone marrow failure.

< 20 x 109/L

Bone marrow failure in presence of additional risk factors: fever, antibiotics, evidence of systemic haemostatic failure.

< 50 x 109/L

Massive haemorrhage or transfusion.In patients undergoing surgery or invasive procedures.Diffuse microvascular bleeding-DIC

< 100 x 109/LBrain or eye surgery.

Any Bleeding PatientAppropriate when thrombocytopenia is considered a major contributory factor.

Any platelet count

In inherited or acquired qualitative platelete function disorders, depending on clinical features & setting.

Dr. Salwa Hindawi

FFP trigger for transfusion

Indications

PT & PTT are more than 1.5 times the upper limit of normal range

Multiple coagulation deficiencies associated with acute DIC.Inherited deficiencies of coagulation inhibitors in patients undergoing high-risk procedures where a specific factor concentrate is unavailable.Thrombotic thrombocytopenia purpura (plasma exchange is preferred)Replacement of single factor deficiencies where a specific or combined factor concentrates is unavailable.Immediate reversal of warfarin effect in the presence or potentially life-threatening bleeding when used in addition to Vitamin K & / or Factor Concentrate (Prothrombin concentrate)The presence of bleeding and abnormal coagulation parameters following massive transfusion or cardiac bypass surgery or in patients with liver disease

Cryoprecipitate trigger for transfusion

Indications

Fibrinogen< 1gm/LCongenital or acquired fibrinogen deficiency including DIC.Hemophilia A, von Willebrand disease (if the concentrate is not available).Factor XIII deficiency.

Dr. Salwa Hindawi

Guidelines for routine blood leucodepletion

1. transfusion dependent patients2. Bone marrow transplant candidates – either autologous /

peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants

3. may be for Patients undergoing intensive chemotherapy regimens4. Previous repeated febrile reactions to red blood cells

Guidelines for blood Irradiation (to prevent TAGVHD)

1.Intrauterine transfusion (IUT) and neonates received IUT.2.One week prior to stem cell collection, and for 12 months post autografting or allografting.3.Hodgkin’s disease4.Treatment with purine analogues (fludarabine, 2-CdA, deoxycofomycin)5.Aplastic anaemia within 6 months of ATG treatment6.Products obtained from close relatives or HLA matched donors.7.Immunodeficiency patients: congenital or acquired

Dr. Salwa Hindawi

• MSBOS is a table of elective surgical procedures that lists the number of units of blood routinely cross-matched pre-operative.

• The ideal value for cross matched to transfused blood, C:T ratio is 1:1 .

• An acceptable value is 3:1 - 2:1 which corresponds to a blood usage of 30-50%.

Maximum Surgical Blood Ordering Maximum Surgical Blood Ordering Schedule (MSBOS)Schedule (MSBOS)

Dr. Salwa Hindawi

Type and Screen (T & S)

• an ABO and Rh type and an antibody screen and antibody identification are done when the patient is admitted.

• only testing necessary if low probability of transfusion

Dr. Salwa Hindawi

Type and Cross (T & C)

• includes an ABO and Rh type and antibody screen and antibody identification.

• in addition includes a crossmatch where

specific units of blood are held back for up to three days for a particular patient.

• for a high probability of transfusion.

Dr. Salwa Hindawi

Crossmatch to Transfusion ratio (C:T ratio)

• blood is used more efficiently when the number of units set aside for a particular patient (crossmatched) are actually transfused.

• C:T ratio is less than 2:1• when a patient does not need blood, it is

good practice to get a T& S but not a T & C

Dr. Salwa Hindawi

Incompatible Blood Transfusion

Clinical Setting

A patient, lacking compatible blood, experiencing

life- threatening, rapid blood loss or hemolysis, in

whom the need for blood replacement is

immediate or urgent.

Dr. Salwa Hindawi

Rarely, facility may lack ABO

compatible blood

* Pan-agglutinin (autoantibody) may be present

* Alloantibody to high frequency antigen may be

present

* Alloantibodies to multiple antigens may be

present

Dr. Salwa Hindawi

Guidelines for Transfusing Incompatible Red Blood Cells

•If patient condition permits, start the transfusion slowly at one ml per minute for the first 15 minutes.

•Observe the patient constantly for symptoms and signs of a reaction. •Take vital signs prior to starting transfusion, whenever a reaction is suspected or, in the absence of a reaction after first 15 minutes, after 30 minutes, and after completion of transfusion.

Dr. Salwa Hindawi

If there is evidence of a transfusion reaction

•Symptoms include fever, pain, apprehension, chills, sweating, tachycardia, or fall in blood pressure.

•STOP the transfusion immediately, maintaining the IV with 0.9% saline.

•Document vital signs at least every 15 minutes throughout the reaction.

Dr. Salwa Hindawi

•If patient condition warrants immediate transfusion:

•Begin another unit of Red Blood Cells per physician order. The new unit also is likely to test as incompatible, but may be tolerated better.

•If further transfusions can be delayed, follow the transfusion reaction policy and resume transfusion after evaluation is complete.

Dr. Salwa Hindawi

If no symptoms or signs of transfusion reaction are noted after 30 minutes

•Proceed with the transfusion and monitor the patient for usual transfusion practices.

•Repeat the entire process for each incompatible Red Blood Cell transfused.

Dr. Salwa Hindawi

Complications of Blood Transfusion

Immediate Delayed

HTR GVHD

FNTR PTP

TRALI Iron overload

Bacterial Infectious

contamination diseases

Allergic, Anaphylaxis

Dr. Salwa Hindawi

TRANSFUSION REACTION WORK-UP FORM

Patient's name:_____________________Date /time : _________________________

File number: ______________________Ward : _____________________________

Number of previous transfusions:_______________

Number of Pregnancies/deliveries :________________

Diagnosis :_______________________________________________________________________________________________________________________________________________________________________

Transfusion date/time startedTransfusion time discontinued :

Temp started:Temp discontinued:

Reaction noted : put if indicated and please specify time reaction started and duration:

Chest Pain Anxiety Hematuria Pruritus

Chills Restlessness Oliguria Pain in legs

Fever Headache Anuria Pain in back

Sweating Urticaria Jaundice Rigor

Nausea Pallor Shock Bronchospasm

Vomiting Erythema Cyanosis Dyspnea

Precordial distress Pulmonary edema

This part should be filled by the physician incharge :

Dr. Salwa Hindawi

This part for blood transfusion services staff:URINE APPERANCE : YELLOW RED DARK BROWN TURBID SERUM PRE TRANSFUSION APPEARANCE: CLEAR HEMOLYSIS ICTERIC SERUM POST TRANSFUSION APPEARANCE: CLEAR HEMOLYSIS ICTERIC Blood CULTURE IF INDICATED : NEGATIVE POSITIVE ___________________________________Patient’s sample and donor unit are correctly identified. Yes NoAmount of blood was transfused : unit # ___________ volume: ____ML unit # _________ volume: ____ML

Patient sampleAnti-A

Anti-B

Anti-

AB

Anti-D

A1 cell

B cell

ABO/Rh

DCT

CC

Anti body screening

Sc1Sc2Sc3

RT

37

AG

CC

RT

37

AG

CC

RT

37

AG

CC

Pre transfusion sample

Immediate post transfusion sample

2nd post transfusion sample ( if possible )

Elution result:___________________________________________________________________________Antibody identification :____________________________________________________________________

Cross matchingcross matchInterp

Pre transfusion sample and unit number:___________________

IS37AHGCC

Pre transfusion sample and unit number:___________________

Post transfusion sample and unit number:___________________

post transfusion sample and unit number:___________________

Dr. Salwa Hindawi

ALTERNATIVES TO BLOOD TRANSFUSION

CRYSTALLOID SOLUTIONS

COLLOID SLOUTIONS

DRUGS: DDAVP

BLOOD SUBSTITUTES: EPO

Dr. Salwa Hindawi

AUTOLOGUS BLOOD TRANSFUSION

1 -Preoperative Collection (PAD)

2-Acute normovolemic haemodilution (ANH).

3 -Red Cell salvage

Dr. Salwa Hindawi

Table 1. Autologous Blood Donation 

Advantages:Disadvantages:

 1. Prevents transfusion-transmitted disease.  2.  Prevents red cell alloimmunization. 3.  Supplements the blood supply. 4.   Provides compatible blood for patients with alloantibodies.   5.  Prevents some adverse transfusion reaction.   6.  Provides reassurance to patients concerned about blood risks.   7.  Is acceptable to many Jehovah’s witnesses.   

 1.  Does not affect risk of bacterialContamination.2.  Does not affect risk of ABO incompatibility 3.  Is more costly than allogenic blood. 4.  Results in wastage of blood not transfused.   5.  Increase prevalence of adverse reactions to autologous donation.   6. Can  subject patients to perioperative anaemia and increased likelihood of transfusion. 

Dr. Salwa Hindawi

Dr. Salwa Hindawi