Blood Transfusion Guidelines in Clinical Practice Salwa Hindawi

Blood Transfusion Guidelines in Clinical Practice Salwa Hindawi MSc, FRCPath, CTM Medical Director of Blood Transfusion Services KAUH 26 th July 2008 Dr. Salwa Hindawi

Introduction Ø Blood Transfusion is not without hazards Ø you should weigh the risk against benefit Ø use of right products to the right patient at the right time Dr. Salwa Hindawi

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

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

ABO Selection of Blood Components Patient ABO Type RBCs, Platelets Plasma & Cryoprecipitate O O O, A, B, AB A A, O A, AB B B, O B, AB AB AB, A, B, O AB Dr. Salwa Hindawi

Principles of Clinical Transfusion Practices v Avoid blood transfusion v Transfusion is only one part of the patient’s management. v Prevention and early diagnosis and treatment of Anemia & underlying condition v Use of alternative to transfusion. eg. IV fluids v Good anesthetic and surgical management to minimized blood loss. Dr. Salwa Hindawi

– 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

– 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 WHEN NECESSARY Dr. Salwa Hindawi

Triggers of Component Transfusion • The lowest threshold for transfusion of components are: • Hb level of 6 -7 g/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

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 14 th 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

Guidelines for blood component therapy Haemoglobin (Hb) trigger for transfusion Indications NB: Hb should not be the sole deciding factor for transfusion. If there are signs or symptoms of impaired oxygen transport < 7 g/d. L 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/d. L Preoperative and for surgery associated with major blood loss. < 9 g/d. L In a patient on chronic transfusion regimen or during marrow suppressive therapy. May be appropriate to control anaemia-related symptoms. < 10 g/d. L Not likely to be appropriate unless there are specific indications. Acute blood loss >30 -40% of total blood volume. Dr. Salwa Hindawi

Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age: 1. Hemoglobin <7 g/d. L with low reticulocyte count and symptoms of anemia 2. Hemoglobin <10 g/d. L with an infant On <35% hood O 2 On O 2 by nasal cannula On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure <6 cm H 2 O Significant apnea or bradycardia Significant tachycardia or tachypnea Low weight gain 3. Hemoglobin <12 g/d. L with an infant On >35% hood O 2 On CPAP/IMV with mean airway pressure 6 to 8 cm H 2 O 4. Hemoglobin <15 g/d. L with an infant On extracorporeal membrane oxygenation (ECMO) Congenital cyanotic heart disease Dr. Salwa Hindawi

Platelet Count trigger for transfusion Indications < 10 x 109/L As 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/L Any Bleeding Patient Any platelet count Brain or eye surgery. Appropriate when thrombocytopenia is considered a major contributory factor. In inherited or acquired qualitative platelete function disorders, depending on clinical features & setting. Dr. Salwa Hindawi

FFP trigger for transfusion PT & PTT are more than 1. 5 times the upper limit of normal range Indications Multiple coagulation deficiencies associated with acute DIC. Inherited deficiencies of coagulation inhibitors in patients undergoing highrisk 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 lifethreatening 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< 1 gm/L Congenital 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 Guidelines for blood Irradiation (to prevent TAGVHD) 1. 2. transfusion dependent patients Bone marrow transplant candidates – either autologous / peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants 3. 4. may be for Patients undergoing intensive chemotherapy regimens Previous repeated febrile reactions to red blood cells 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 disease 4. Treatment with purine analogues (fludarabine, 2 -Cd. A, deoxycofomycin) 5. Aplastic anaemia within 6 months of ATG treatment 6. Products obtained from close relatives or HLA matched donors. 7. Immunodeficiency patients: congenital or acquired Dr. Salwa Hindawi

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

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 This part should be filled by the physician incharge : Patient's name: ___________ Date /time : _____________ File number: ___________ Ward : _______________ Number of previous transfusions: ________ Number of Pregnancies/deliveries : ________ Diagnosis : ____________________________________________________________________________________ Transfusion date/time started Transfusion 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 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 No Amount of blood was transfused : unit # ______ volume: ____ML unit # _____ volume: ____ML Patient sample Ant i. A Ant i. B Ant i. AB Anti body screening Ant i-D A 1 cell B cell ABO/ Rh D CT C C Sc 1 R T 3 7 A G Sc 2 C C R T 3 7 Pre transfusion sample Immediate post transfusion sample 2 nd post transfusion sample ( if possible ) Elution result: ______________________________________ Antibody identification : __________________________________ Cross matching Pre transfusion sample and unit number: __________ cross match IS 37 Pre transfusion sample and unit number: __________ Post transfusion sample and unit number: __________ post transfusion sample and unit Dr. Salwa Hindawi number: __________ AHG Interp C C A G Sc 3 C C R T 3 7 A G C C

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 Disadvantages: Advantages: 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 bacterial Contamination. 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

Dr. Salwa Hindawi