Blood Transfusion Update for General Practice Hospital Transfusion

Blood Transfusion Update for General Practice Hospital Transfusion Team RD&E rde-tr. HTT@nhs. net. Respond Deliver & Enable

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 Respond Deliver & Enable

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 Guidance • Some 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 units • All transfusion requests will be reviewed by a member of the Hospital Transfusion Team Respond Deliver & Enable

SECTION 1 • When is transfusion appropriate? • How many units should I prescribe? Respond Deliver & Enable

Indication for transfusion • Haemoglobin trigger levels for transfusion are well established • They 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 Respond Deliver & Enable

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

Transfusion in Patients who are not acutely bleeding National Guidance ( NBTC 2013) • In chronic anaemia aim to maintain haemoglobin levels so as to prevent symptoms of anaemia • Transfusing when haemoglobin levels fall below 80 g/l is appropriate for many patients Respond Deliver & Enable

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 80 g/l • For chemotherapy patients maintain Hb above 80 -90 g/l • For radiotherapy patients maintain Hb above 100 g/l As ever be guided by your patient’s symptoms rather than their numbers Respond Deliver & Enable

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

Is transfusion appropriate? • 78 yr old man with a microcytic anaemia of 72 g/l, who is slightly breathless on exertion • The anaemia is being fully investigated • He is intolerant of oral iron • Should you arrange a transfusion? Respond Deliver & Enable

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 Respond Deliver & Enable

So in this patient…. . • Arrange for patient to have an intravenous iron infusion • If 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 Respond Deliver & Enable

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

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 kg • In a ‘little elderly lady’ weighing 50 kgs, the Hb may rise by 15 to 20 g/l after 1 unit • It is very rare to need to transfuse anyone to over 100 g/l Respond Deliver & Enable

So in this case…. . • She has a haemoglobin of 70 g/l and given her size every unit will increase her haemoglobin by at least 15 g/l • You 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 100 g/l • If you prescribed 3 units, you would over transfuse her and unnecessarily put her at risk of cardiac overload and other transfusion reactions Respond Deliver & Enable

SECTION 2 The practicalities of arranging a blood transfusion Respond Deliver & Enable

Patient Consent to Blood Transfusion • Where possible patients should have the risks, benefits and alternatives to transfusion explained to them • Record reason for transfusion consent in notes • Provide written information, leaflets available within all community hospitals Respond Deliver & Enable

Risks of blood transfusion • 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 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 Respond Deliver & Enable

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 band • Always write details on the tube straight away and AT the bedside • Only take blood and label samples for one patient at a time Respond Deliver & Enable

Patient Identification Errors • We 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 label • There are 2 main causes for this: – Failure to identify the patient correctly – Failure to label the sample at the bedside Respond Deliver & Enable

The Request Form…. . This is your way of communicating with our lab staff PLEASE: • Tell us the name of the GP making the request so if there 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 any difficulties Respond Deliver & Enable

Completing the request form…. . Use patient sticker or hand write: • Hospital or NHS number • Surname • Fore name • Date 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… Respond Deliver & Enable

Special Requirements: Irradiated Blood • Irradiating donated blood removes any remaining leucocytes, this eliminates the risk of Transfusion Associated Graft vs Host disease • This is a rare but frequently fatal complication of blood transfusion • Some patients because of present or prior treatment or illness are at increased risk of Ta. Gv. H disease and require irradiated blood Respond Deliver & Enable

Who needs Irradiated blood? • In the community, consider if patient has history of : – – Chemotherapy with purine analogues eg fludarabine Hodgkin's disease either in the past or present Bone marrow transplant Has been treated with anti-CD 52 antibodies or anti-thymocyte globulin • This 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 Respond Deliver & Enable

What about the Cytomegalovirus box? ? • CMV screened red cells & platelets are only needed for – neonates and intra uterine blood transfusions – Planned transfusions during pregnancy – Some granulocyte transfusions • In the community you are pretty safe to tick the no box! Respond Deliver & Enable

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 samples • Over 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 Laboratory • If 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 Respond Deliver & Enable

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 days • In transfusion dependent haematology patients it may be possible to waive the 72 hr rule after discussion with their consultant Respond Deliver & Enable

Time to blood transfusion from taking blood sample……. • Day 1: • Day 2: • Day 3: Blood sample taken in Community arrives in lab on transport at 3 pm when the blood sample will be cross matched but not in time for the routine transport out which leaves at 4 pm each day Blood transported to Community Hospital, leaving RD&E at 4 pm Blood Transfusion Respond Deliver & Enable

Section 3 Safe Administration of blood: Blood Transfusion Reactions Respond Deliver & Enable

A patient is 10 minutes into the start of a blood transfusion • She complains of feeling itchy, develops an urticarial rash and feels light headed • The nurses contact you for advice • What is this likely to be and what should your first action be? Respond Deliver & Enable

This is likely to be an acute transfusion reaction • Key action is to STOP the transfusion • Follow the Transfusion Reaction Chart which is available on the ward • The on call haematologist may need to be involved Respond Deliver & Enable

Acute Transfusion Reactions Within 24 hrs of transfusion 1. Febrile reactions, often mild 2. Allergic reactions ranging from urticaria to anaphylaxis 3. Acute Haemolytic Reactions eg ABO incompatibility 4. Bacterial contamination range from mild pyrexia to septic shock 5. Transfusion - associated circulatory overload (TACO) 6. Transfusion – related lung injury (TRALI) Respond Deliver & Enable

A frail 85 year old man is having his 3 rd unit of blood and starts to feel breathless • What should you do? • What is the likely diagnosis? • How can you try and prevent this happening again? Respond Deliver & Enable

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 transfusion • It is now the leading cause of mortality related to blood transfusion in the UK ; 9 deaths and 32 patients admitted to HDU last year Respond Deliver & Enable

What should you do? • Stop the transfusion • Assess patient as per Blood Transfusion Reaction protocol • If you think this is TACO, treat as Left Ventricular failure, the patient will need a CXR and admission to RD&E or NDDH • Contact the Consultant Haematologist on call Respond Deliver & Enable

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 cover – Ask nursing staff to observe for signs of fluid overload – Single unit transfusions are advised Respond Deliver & Enable

Delayed Transfusion Reaction • A patient who had a transfusion 8 days ago presents to you feeling generally unwell, with dark urine and loin pains • Apart from a UTI, what else would you consider? Respond Deliver & Enable

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 failure • Initial 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 Respond Deliver & Enable

5 Key Points…. . 1. Transfuse appropriately using haemoglobin trigger levels 2. Try not to over transfuse, remember size does matter 3. Use oral or iv iron in patients with iron deficiency rather than blood transfusion 4. Identify patients correctly; ‘Right Blood Right Patient every time’ 5. Transfusion related Circulatory Overload (TACO) is highest cause of mortality from transfusion Respond Deliver & Enable

Thank You!! Hospital Transfusion Team RD&E rde-tr. HTT@nhs. net. Respond Deliver & Enable