Blood Transfusion Guidelines in Clinical Practice

1. Blood Transfusion Guidelines in Clinical Practice Salwa Hindawi MSc, FRCPath, CTM Medical Director of Blood Transfusion Services KAUH 26th July2008 Dr. Salwa Hindawi

2. 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

3. Donor Patient 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 Dr. Salwa Hindawi

4. Platelets rich plasma Platelets concentrate 2nd centrifugation Whole blood Whole blood Whole blood 1stcentrifugation FFP for clinical use Red Cell concentrate FFP for fractionation Fresh plasma Optimal additive solution Cryoprecipitate Red cells in OAS Dr. Salwa Hindawi

5. ABO Selection of Blood Components Dr. Salwa Hindawi

6. 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

7. Prescribing should be based on national guidelines on the clinical use of blood taking individual patient needs into account. • Hb level should not be the sole deciding Factor Clinical evaluation is important Dr. Salwa Hindawi

8. 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

9. 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

10. WHEN WE SHOULD TRANSFUSE BLOOD ?&WHAT BLOOD COMPONENT SHOULD BE TRANSFUSED ? Dr. Salwa Hindawi

11. TO TRANSFUSE BLOOD WHEN NECESSARY Dr. Salwa Hindawi

12. Triggers of Component Transfusion • 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 Dr. Salwa Hindawi

13. 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. Williamson LM. Transfusion Trigger in the UK. Vox sang 2002. AABB Technical Manual 14th ed, 2002. Dr. Salwa Hindawi

14. 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

15. Guidelines for blood component therapy Guidelines for blood component therapy Dr. Salwa Hindawi

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20. Maximum Surgical Blood Ordering Schedule (MSBOS) • 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%. Dr. Salwa Hindawi

21. 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

22. 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

23. 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

24. Incompatible Blood TransfusionClinical SettingA 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Complications of Blood Transfusion Immediate Delayed HTR GVHD FNTR PTP TRALI Iron overload Bacterial Infectious contamination diseases Allergic, Anaphylaxis Dr. Salwa Hindawi

31. TRANSFUSION REACTION WORK-UP FORM This part should be filled by the physician incharge : Reaction noted : put  if indicated and please specify time reaction started and duration: Dr. Salwa Hindawi

32. 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 No Amount of blood was transfused : unit # ___________ volume: ____ML unit # _________ volume: ____ML Elution result:___________________________________________________________________________ Antibody identification :____________________________________________________________________ Dr. Salwa Hindawi

33. ALTERNATIVES TO BLOOD TRANSFUSION CRYSTALLOID SOLUTIONS COLLOID SLOUTIONS DRUGS: DDAVP BLOOD SUBSTITUTES: EPO Dr. Salwa Hindawi

34. AUTOLOGUS BLOOD TRANSFUSION 1- Preoperative Collection (PAD) 2-Acute normovolemic haemodilution (ANH). 3- Red Cell salvage Dr. Salwa Hindawi

35. Table 1. Autologous Blood Donation Dr. Salwa Hindawi

36. Nowing is not enough we must apply. Willing is not enough we must do. Johann Von Goethe Dr. Salwa Hindawi

37. Thanks Dr. Salwa Hindawi