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Blood Transfusion Dr Emer Lawlor, IBTS 3rd February 2003

Blood Transfusion Dr Emer Lawlor, IBTS 3rd February 2003. First Blood Transfusions. Harvey Discovered Circulation of Blood. 1628. Wilkins & Lower Transfusions from dog to dog. 1665-’66. 1667. Jean-Baptiste Denis Performed first recorded blood transfusions from animals to humans.

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Blood Transfusion Dr Emer Lawlor, IBTS 3rd February 2003

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  1. Blood TransfusionDr Emer Lawlor, IBTS3rd February 2003

  2. First Blood Transfusions Harvey Discovered Circulation of Blood 1628 Wilkins & Lower Transfusions from dog to dog 1665-’66 1667 Jean-Baptiste Denis Performed first recorded blood transfusions from animals to humans

  3. 19th Century Transfusions 1818 James Blundell, Obstetrician First transfusion of human to human

  4. Early transfusion: Paris, France

  5. 20th Century Transfusions 1901 Karl Landsteiner Discovers A, B, O Blood Groups

  6. 20th Century Transfusions 1902 AB Group discovered Importance of crossmatching blood between donor & recipient 1907 Sodium Citrate proposed as anticoagulant 1914 1936 First Blood Bank: Barcelona, Spanish Civil War Levine & Landsteiner, Rhesus blood Group System 1940

  7. Bad Blood France, Switzerland, Italy, Netherlands, Germany, Denmark, Ireland, Australia, New Zealand, Canada, USA Japan

  8. Aims of Transfusion Centre • Provision of Blood of the best possible quality and safety for the patient receiving it • To care for the donor - ensure act of donation does not harm donor

  9. Blood Supply Chain • Blood Donor Screening Criteria • Donation Process • Donation Testing • Component preparation • Plasma Products

  10. Donor Screening • Self deferral of ‘At Risk’ groups • Health Questionnaire • Microbiological screening of each donation

  11. Blood Donor Criteria • Age 17-65 ( new donors until 60) • Weight > 50kg ( 7st 12Ibs) • General health • Specific illnesses • Contact with infection

  12. Blood Donor Criteria • HIV,Hepatitis risk • Medication • CJD • Hb > 13 M; >12 F

  13. Haemoglobin Testing

  14. Alternatives to Voluntary Donors: Autologous • 5-10% of patients are fit to predeposit autologous blood • Orthopaedic, Plastic Surgery, Gynaecology • Up to 5 units can be predeposited/1 week • Increased donor reactions • Still have risk of : Clerical error, Bacterial Infections

  15. Alternatives to Voluntary Donors: Directed • Relatives or friends • Not demonstrably safer • Not voluntary • Viral marker rates higher as often first time donors • TA-GVHD

  16. Blood Donation • 475mls Blood + 63mls anticoagulant Red Cells Plasma Buffy Coat Platelets • Red Cells + Optimal Additive Solution Saline Adenine SAGM Glucose Mannitol • Expiry date 35 days

  17. Blood Components and Products

  18. Blood Component Production

  19. Blood Component Production

  20. Leucodepletion • Universal leucodepletion introduced in 1999 to reduce the risk of vCJD transmission by blood • other benefits - less febrile reactions, less alloimmunisation, less GVHD, ? reduce immunosuppresssive effects

  21. Leucodepletion

  22. Platelets • Pools prepared from buffycoats of whole blood donations (4 donations)- • Apheresis concentrates from one donor using a cell separator • pool/apheresis pack (250mls) = standard adult dose

  23. Blood Donation Testing • Microbiology markers • Blood grouping and screening for high titre antibodies • Quality monitoring

  24. A O B

  25. ABO Groups

  26. Frequency of ABO & Rh(D) Groups in Ireland • Group O 56% • Group A 31% • Group B 11% • Group AB 2.5% • Rh (D) positive 85% • Rh (D) negative 15%

  27. ABO Grouping Patient Red Cells Test Reagents

  28. Cells v Serum Serum v Cells

  29. Current anti HIV 1+2 HIV PCR HBsag HBc assay anti HCV HCV PCR anti HTLV1/2 syphilis anti CMV Future Bacterial culture of components Prions Microbiology testing

  30. Hospital Blood Transfusion Laboratory Patient/donor testing and product selection and issue

  31. Tests prior to transfusion Hospital IBTS • ABO & Rh typing • Antibody screen Patient Donor Donor • ABO & Rh typing • Antibody screen Compatibility Test (x-match) Donor red cells + patients serum Saline and LISS Coombs

  32. Antigens on Red Cells

  33. Blood Group Antibodies 1. Naturally occurring: - ABO - Anti-Hi, P1, E Immune 2. Pregnancy: - Rhesus, Kell, Fya + Others 3. Transfusion: - Rh, Kell, Fy, JKa + Others

  34. Conventional Testing. Weak reactions often difficult to interpret. Can also be downgraded due to shaking the completed test.

  35. Principle of Gel Technology • The sephadex gel matrix acts as a sieve. • Large agglutinates remain on or near the top of the gel interface. • Smaller agglutinates pass partway through the gel, depending on size. • Unagglutinated cells pass to the base of the microtube

  36. ABO/Rh Typing Group B RhD positive

  37. Antibody Screening Positive antibody screen. Antibody could cause a transfusion reaction or affect an unborn baby.

  38. Purpose of Crossmatch • Detect unsuspected ABO incompatibility Donor centre Error in laboratory • Detection of unsuspected antibodies in <1% cases

  39. Crossmatching Crossmatch ABO Group Donor and patient compatible. Unit safe to transfuse. Patient B Positive Recipient Serum Donor Red Cells

  40. Electronic Crossmatch • Donor units • Repeat ABO Rh groups performed on all donor units • Automated Grouping • Validated computer software to ensure that ABO incompatible units cannot be selected for patient

  41. Blood Component Storage • Whole blood/red cells - 2-6C for up to 35 days use within 5 hours of removal from blood fridge • Platelets -20-24C on agitator for 5 days • SD Fresh frozen plasma ( FFP) for 6 months - use within 4 hrs of thawing • Cryoprecipitate -30C use within 4 hours of thawing

  42. Haemovigilance Looping the Loop Safety of the Transfusion Chain from Vein to Vein Right Blood Right Patient Right Time = + + 

  43. Transfusion Chain • Supply from Transfusion Centre • Patient and sample identification • Transport of sample to laboratory • Laboratory ordering/testing process • Storage • Delivery of blood unit to patient • Administration • Monitoring • Adverse Reaction reporting • Guidelines,Audit and Review (outside loop)

  44. Transfusion Chain • Hospital • patient & sample • Identification • Haemovigilance • Adverse Reaction • reporting • Guidelines, Audit • & review • Transfusion • Centre • Blood Supplied • Laboratory • Ordering • Testing • Storage • Patient • Blood Administered • Monitored

  45. NHO Incidents (category) 1999-2001

  46. Transfusion Chain • Supply from Transfusion Centre • Patient and sample identification • Transport of sample to laboratory • Laboratory ordering/testing process • Storage • Delivery of blood unit to patient • Administration • Monitoring • Adverse Reaction reporting • Guidelines,Audit and Review

  47. IBCT (n=31) ‘Site of First Error’

  48. Wrong Pre-Transfusion Samples • 2 cases in the first two years of NHO reporting • NHO audit 2000: 40% samples not labelled at bedside as per guidelines or prelabelled • Untoward incident reports St Elsewhere’s 2000 • 8 wrong patient samples bled • samples out of hours • non phlebotomy staff • prelabelled tubes • musical beds Near Misses only because lab had historic group on patient!

  49. Wrong ABO Group - Case 1 • Pre transfusion sample was taken from wrong patient. • Patient received an ABO incompatible transfusion. • Transfusion reaction investigations led to the identification of multiple errors. NHO Report, 2001

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