Blood Transfusion Update for General - PowerPoint Presentation

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Blood Transfusion Update for General Practice

Hospital Transfusion TeamRD&Erde-tr.HTT@nhs.net.

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Welcome to Transfusion Training!The aim of this training is to support you as General Practitioners in making appropriate, safe decisions when you request and prescribe blood There is a national mandatory requirement for all involved in the process of blood transfusion to have regular 3 yearly training, which this training will fulfil

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Update from the Hospital Transfusion Team..The RD&E transfusion laboratory is now cross matching a maximum of 2 units for transfusion for one patient in 24 hrs

This is in response to recent audit and National GuidanceSome patients, particularly transfusion dependent haematology patients, may have a higher transfusion requirement, please discuss with the patient’s consultants if you feel you need more than 2 unitsAll transfusion requests will be reviewed by a member of the Hospital Transfusion Team

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SECTION 1When is transfusion appropriate? How many units should I prescribe?

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Indication for transfusionHaemoglobin trigger levels for transfusion are well establishedThey are one of the reasons that there has been a national 20% reduction in the use of RBC transfusions in the last 15 yrs.There is increasing evidence in patients who are not acutely bleeding that a restrictive transfusion policy reduces patient mortality and morbidity

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Is transfusion appropriate?A 78yr old patient with a chronic normochromic normocytic anaemia has a haemoglobin of 85g/l. What do the national guidelines say?Should you transfuse?

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Transfusion in Patients who are not acutely bleedingNational Guidance ( NBTC 2013)

In chronic anaemia aim to maintain haemoglobin levels so as to prevent symptoms of anaemiaTransfusing when haemoglobin levels fall below 80g/l is appropriate for many patients  

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Some patients will do better with higher oxygen delivery…..Haematology or Renal patients often have a higher transfusion requirement, be guided by symptoms and consultants

Patients who have cardiovascular disease have higher oxygen requirements to remain symptom free, aim to keep haemoglobin levels above 80g/lFor chemotherapy patients maintain Hb above 80-90g/lFor radiotherapy patients maintain Hb above 100g/l

As ever be guided by your patient’s symptoms rather than their numbers

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So in this patient…..The haemoglobin is not at the trigger level for transfusion but clearly the decision must be made on individual symptomsIf his symptoms do warrant transfusion, one unit is all he is likely to need.

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Is transfusion appropriate? 78 yr old man with a microcytic anaemia of 72 g/l, who is slightly breathless on exertionThe anaemia is being fully investigatedHe is intolerant of oral iron

Should you arrange a transfusion?

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Iron Deficiency Anaemia (IDA)In IDA, patients need iron rather than blood unless there are symptoms of end organ failure

IV iron now much safer to give and readily available within the RD & E (AMU will arrange) 1 gram of iron can be infused over 60 minutes, this is the amount of iron contained in 4 units of blood

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So in this patient…..Arrange for patient to have an intravenous iron infusionIf you feel patient’s symptoms mean that you need to increase his haemoglobin more quickly than the 7-14 days it will take with intravenous iron, then a 1 unit transfusion followed by iv iron may be appropriate

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How many units to prescribe? An 84 yr old lady with a longstanding anaemia of chronic disease has a haemoglobin of 70g/l and is feeling breathless and a bit dizzy on standing. She weighs 50 kgHow many units should you prescribe?

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Why give 2 when 1 will do?The rule that 1 unit of blood increases

Hb by 10 g/l only holds for someone of 70 kgIn a ‘little elderly lady’ weighing 50kgs, the Hb may rise by 15 to 20 g/l after 1 unitIt is very rare to need to transfuse anyone to over 100 g/l

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So in this case…..She has a haemoglobin of 70g/l and given her size every unit will increase her haemoglobin by at least 15g/lYou could bring her in for 1 unit and check her haemoglobin and then bring her in again for another unit if needed, but in the community this may be difficult and you may want to give her 2 units to bring her

Hb up to 100g/lIf you prescribed 3 units, you would over transfuse her and unnecessarily put her at risk of cardiac overload and other transfusion reactions

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SECTION 2The practicalities of arranging a blood transfusion

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Patient Consent to Blood TransfusionWhere possible patients should have the risks, benefits and alternatives to transfusion explained to them Record reason for transfusion consent in

notesProvide written information, leaflets available within all community hospitals

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Risks of blood transfusion

1 : 1 300 samples

Sample does not contain the blood of the person named on the sample label

1 : 10 000 units

Severe transfusion reaction

1 : 13 000 units

Blood component transfused to the wrong patient

1: 1.3 million units

Hepatitis B

1: 6.5 million units

HIV/AIDS

1: 28 million

Hepatitis C

unknown

CJD

Transfusion is very safe in UK but preventable death and major morbidity still occur

Inappropriate transfusions put patients at unnecessary risk of identification errors, transfusion reactions and infections

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Taking the blood……Ask the patient for their name and date of birth,

let them tell you.If they are inpatients always check the ID bandAlways write details on the tube straight away and AT the bedside

Only take blood and label samples for one patient at a time

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Patient Identification ErrorsWe detect an average of 6 Wrong Blood in Tube (WBIT) incidents per year

WBIT means that the blood in the sample bottle is not the blood of the patient whose details are written on the labelThere are 2 main causes for this:Failure to identify the patient correctlyFailure to label the sample at the bedside

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The Request Form…..This is your way of communicating with our lab staffPLEASE: Tell us the name of the GP making the request so if there are any difficulties we can contact you

Tell us why you are transfusing the patient ( not just low hb..) and their pre transfusion haemoglobin level Tell us where the blood needs to be sent to and what day/time it is needed, we will be able to alert you earlier if there are any difficulties

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Completing the request form…..

Use patient sticker or hand write: Hospital or NHS number

SurnameFore nameDate of birth

Please add requesting

Gp

name,

so that we know who to contact

Complete special requirements

Number of units when and where

transfusion will take place

Meaningful reason for transfusion not low

Hb

if possible…

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Special Requirements: Irradiated BloodIrradiating donated blood removes any remaining leucocytes, this eliminates the risk of Transfusion Associated Graft

vs Host diseaseThis is a rare but frequently fatal complication of blood transfusionSome patients because of present or prior treatment or illness are at increased risk of TaGvH disease and require irradiated blood

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In the community, consider if patient has history of :

Chemotherapy with purine analogues eg fludarabineHodgkin's disease either in the past or presentBone marrow transplant

Has been treated with anti-CD52 antibodies or anti-thymocyte globulinThis list is now available on the back of transfusion forms

There is a system for identifying these patients at diagnosis and a warning system on the laboratory computer, ask the lab if you are not sure

Who needs Irradiated blood?

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What about theCytomegalovirus box??

CMV screened red cells & platelets are only needed for neonates and intra uterine blood transfusionsPlanned transfusions during pregnancySome granulocyte transfusions  In the community you are pretty safe to tick the no box!

 

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Taking the sample.. How many do you need to take? The RD&E needs confirmation of a patient’s ABO group from 2 separate samples to reduce the risk from mislabelled samplesOver 90% of patients already have a group recorded on our computer system and just need 1 new sample for cross match

If you are unsure of how many samples to take please ring the Transfusion LaboratoryIf taking 2 samples they should be taken from 2 venepunctures with 2 SEPARATE attempts at patient identity, please use 2 forms with time difference on samples

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Taking the sample.. How far in advance of the transfusion can it be taken? The standard sample validity time is 72 hours between sampling and transfusion

If no pregnancy or transfusion within previous 3 months then the sample validity time extends to 7 daysIn transfusion dependent haematology patients it may be possible to waive the 72 hr rule after discussion with their consultant

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Time to blood transfusion from taking blood sample…….Day 1: Blood sample taken in Community arrives in lab on transport at 3pm when the blood sample will be cross matched but not in time for the routine transport out which leaves at 4 pm each day

Day 2: Blood transported to Community Hospital, leaving RD&E at 4 pmDay 3: Blood Transfusion

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Section 3Safe Administration of blood:

Blood Transfusion Reactions

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A patient is 10 minutes into the start of a blood transfusionShe complains of feeling itchy, develops an urticarial rash and feels light headedThe nurses contact you for adviceWhat is this likely to be and what should your first action be?

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This is likely to be an acute transfusion reactionKey action is to STOP the transfusion

Follow the Transfusion Reaction Chart which is available on the wardThe on call haematologist may need to be involved

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Acute Transfusion ReactionsWithin 24 hrs

of transfusionFebrile reactions, often mildAllergic reactions ranging from urticaria to anaphylaxis

Acute Haemolytic Reactions eg ABO incompatibilityBacterial contamination range from mild pyrexia to septic shockTransfusion - associated circulatory overload (TACO)

Transfusion – related lung injury (TRALI)

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A frail 85 year old man is having his 3rd unit of blood and starts to feel breathlessWhat should you do?

What is the likely diagnosis?How can you try and prevent this happening again?

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This is likely to be Transfusion Associated Circulatory Overload (TACO)

This is defined as acute or worsening pulmonary oedema within 6 hours of a blood transfusionIt is now the leading cause of mortality related to blood transfusion in the UK ; 9 deaths and 32 patients admitted to HDU last year

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What should you do? Stop the transfusionAssess patient as per Blood Transfusion Reaction protocolIf you think this is TACO, treat as Left Ventricular failure, the patient will need a CXR and admission to RD&E or NDDHContact the Consultant Haematologist on call

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Who is at risk of TACO? Patients over 70 yrs old of low weight with cardiac or renal failure or a low albumin are higher risk of TACO

In these patients: Clearly record reason for transfusion, is this transfusion really necessary?Assess patient before transfusion and if at risk transfuse slowly, consider diuretic coverAsk nursing staff to observe for signs of fluid overloadSingle unit transfusions are advised

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Delayed Transfusion ReactionA patient who had a transfusion 8 days ago presents to you feeling generally unwell, with dark urine and loin painsApart from a UTI, what else would you consider?

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This could be a delayed transfusion reaction..These occur up to 14 days post transfusion They present with features of haemolysis, with a

less than expected rise in haemoglobin levels post transfusion, jaundice, fever, haemoglobinuria, acute renal failureInitial blood tests should include a repeat Group and Save, also requesting a DAT (Direct Antiglobulin Test) on the same form, FBC and LFTs.

Easy to miss, treatment is supportive, refer for investigation to clarify nature of antibody for future transfusions

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5 Key Points…..Transfuse appropriately using haemoglobin trigger levelsTry not to over transfuse, remember size does matter

Use oral or iv iron in patients with iron deficiency rather than blood transfusion Identify patients correctly; ‘Right Blood Right Patient every time’Transfusion related Circulatory Overload (TACO) is highest cause of mortality from transfusion

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Thank You!!Hospital Transfusion TeamRD&Erde-tr.HTT@nhs.net.