Guide tranblood24jan2014112621


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Guide tranblood24jan2014112621

  1. 1. 1
  2. 2. 2 The 5 Rights of Transfusion Ensure that the Right Patient is getting the Right Product in the Right Amount at the Right Rate at the Right Time
  3. 3. 3 Contents S. No. Topic Page No. 1. Pre-transfusion phase 5-17 1.1 Informed consent 5 1.2 Types of Blood Products 6-9 1.3 Blood requisition 10-11 1.4 Process flow from requisition to issue of blood 12-14 1.5 Blood request in extreme emergency ( Life threatening bleed) 15 1.6 Requisition of Single Donor Apheresis Platelet (SDAP) 16-17 1.7 Blood group compatibility for blood components 18 1.8 Preparing the patient for transfusion 19 1.9 Need for warming blood before transfusion 20 1.10 Blood transfusion Set 21 1.11 Final Check before transfusion 22 2. Transfusion Phase 23-28 2.1 Starting and Monitoring blood transfusion 23-24 2.2 Documentation 25 2.3 Transfusion reactions 26-28 2.4 Hemovigilance 28 Annexure 1 : Patient Consent form Annexure 2 : Blood Bag Labels and compatibility report ( Reaction form) Annexure 3: Transfusion record Sheet Annexure 4: Process flow for arrangement of blood unit for intrauterine transfusion
  4. 4. 4 Blood and blood products are categorised as drugs as per the Drugs and cosmetics Act, Government of India and hence the processing, issue and transfusion should be in compliance with the rules therein.
  5. 5. 5 1.1 INFORMED CONSENT Reference standards issued by Blood safety Division, National AIDS Control Organisition Ministry of Health and Family Welfare Government of India The patient should be informed about his/her need for blood, alternatives available, as well as risks involved in transfusion and non transfusion. His/ her written consent should be taken in the language he / she understands best only after providing information. For minors and unconscious patients the next of kin should sign the informed consent. Guidelines for the person obtaining consent: Describe the blood product to be transfused. Inform the patient or alternate decision maker of material risks and benefits of the transfusion and any alternatives. Give the patient the opportunity to ask questions. Document that consent was obtained by completing a transfusion consent form. (Appendix: 1) Clearly document the reason for transfusion in the patient’s chart. Whenever possible, consent for transfusion should be discussed early enough to allow for blood alternatives to be considered
  6. 6. 6 1.2 Types of Blood Products With advancements in types of blood bags and component preparation techniques, whole blood from a single blood donor can be divided into three or four blood components preserving the function of individual component by storing them at desired temperature and issuing specific component as per patient’s need. Following are the types of blood Products available in Department of Transfusion Medicine. Whole Blood (WB) Packed Red blood cells (PRBC) in CPDA-1 SAGM-PRBC ( Packed Red Cells in additive solution Paediatric PRBC units ( Volume 80-100ml)* Platelet Concentrate (PC) Fresh Frozen Plasma (FFP) Cryopoor Plasma (CPP) Cryoprecipitates (Cryo) Apheresis Platelets (SDAP) Granulocyte concentrates Description of each component about its volume, content, storage conditions, indications, their administration guidelines are given in Table 1, 2 and 3. *Paediatric PRBC units are prepared by dividing adult PRBC unit into three parts using sterile connecting device and transfer bags.
  7. 7. 7 Table 1: Red Cell products Parameters Whole blood PRBC (CPDA-1) PRBC-SAGM Description Whole blood collected from blood donor in CPDA-1 Solution Red blood cell concentrate From which most of plasma has been removed Red cell concentrate from which major part of the plasma and the buffy coat layer has been removed with subsequent addition of a nutrient Solution (SAGM). Volume 399 ml ( 350 blood + 49 ml CPDA-1) and 513 ml ( 450 blood + 63 ml CPDA-1) 200 to 300 ml 250 to 350 ml Hemoglobin 12 g /100ml 20 g/ 100 ml ( ≥45g /bag) ≥45g /bag Hematocrit 30-40% 65-75% 55-65% Storage conditions +2 to +6o C in approved blood bank refrigerator, with fitted temperature chart and alarm +2 to +6o C in approved blood bank refrigerator, with fitted temperature chart and alarm +2 to +6o C in approved blood bank refrigerator, with fitted temperature chart and alarm Shelf life 35 days 35 days 42 days Indications • Red cell replacement in acute blood loss • Exchange transfusion • Patient needing red cell transfusions where PRBCs are not available • Replacement of red cells in anaemic patients • In acute blood loss along with crystalloids and colloids • Replacement of red cells in anaemic patients • Patients who have experienced febrile reactions to previous red cell transfusion. Administration • Transfuse using standard blood transfusion set with 170µm filter. • Transfusion should be started within 30 minutes of removal from refrigerator & Complete transfusion within 4 hours of commencement • Transfuse using standard blood transfusion set with 170µm filter. • Transfusion should be started within 30 minutes of removal from refrigerator & Complete transfusion within 4 hours of commencement • Transfuse using standard blood transfusion set with 170µm filter. • Transfusion should be started within 30 minutes of removal from refrigerator & Complete transfusion within 4 hours of commencement
  8. 8. 8 Table 2: Platelet products Parameters Platelet concentrate (PC) Apheresis platelets ( SDAP) Description Platelet Concentrrates are prepared from either 350 ml or 450 ml whole blood.They are also called Random donor platelets (RDP) Platelet concentrate derived from blood donor using an apheresis machine and disposable kit. It is also called single donor apheresis platelets (SDAP) Volume 50 to 90 ml 200-300ml Platelet content 3.5 to 4.5 X 1010 /unit 3 to 7 X 1011 /unit (6 to 8 times the content in RDP) Dosage 1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6 single donor units One pack of platelet concentrate collected from a single donor by apheresis is usually equivalent to one therapeutic dose Storage and Shelf life 3 to 5 days at 20°C to 24°C (with agitation) 5 days at 20°C to 24°C (with agitation) Do not store at 2°C to 6°C in Refrigerators as it makes them non-functional Indications • Thrombocytopenia • Platelet function defects • Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure • Same as for RDPs • Patients experiencing frequent febrile Reactions with platelet concentrate Administration • Transfuse using standard blood transfusion set with 170µm filter. • Initiate transfusion slowly for first 15 minutes unless massive blood loss. Same as Random donor platelets, but ABO compatibility is more important Caution: Platelets are prone to develop bacterial contamination, Transfusion should be started immediately after receiving the units in the ward and Should be completed over a period of about 30 minutes.
  9. 9. 9 Table 3: Plasma products Parameters Fresh frozen plasma (FFP) Cryoprecipitates Description Plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –30°C or colder Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C. Volume 150–220 ml 15 to 20 ml Content Contains normal plasma levels of stable clotting factors, albumin and immunoglobulins. Factor VIII level at least 70% of normal fresh plasma levels. Factor VIII: 80–100 IU/ bag; fibrinogen: 150–300 mg/bag Dosage Initial dose of 15 ml/kg 1 bag / 10 kg body weight Storage And shelf life At –30°C or colder for up to 1 year At –30°C or colder for up to 1 year Indications Replacement of multiple coagulation factor deficiencies: e.g. • Liver disease • Warfarin (anticoagulant) overdose • Depletion of coagulation factors in patient receiving large volume transfusions • Disseminated intravascular coagulation (DIC) • Thrombotic thrombocytopenic purpura (TTP) • As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: von Willebrand Factor (von Willebrand’s disease) Factor VIII (haemophilia A) • Factor XIII • As a source of fibrinogen in acquired coagulopathies: e.g.disseminated intravascular coagulation (DIC) Administration • Must normally be ABO compatible to avoid risk of haemolysis in recipient. • Infuse using a standard blood administration set (with 170µm filter) as soon as possible after thawing. • Labile coagulation factors rapidly degrade; use within 6 hours of thawing • Can be transfused across ABO barrier. • After thawing, infuse as soon as possible through a standard blood administration set. • Must be infused within 6 hours of thawing.
  10. 10. 10 1.3 REQUISITION FOR BLOOD AND BLOOD COMPONENTS Pre-transfusion Sample collection Patient Identification: 1. Even if you know your patient, check your patient’s identification on patient file to make sure it is correct. 2. Include your patient in the identification process by asking specific questions: • What is your name • ‘How do you spell your name?’ • AVOID questions that require only a ‘Yes’ or ‘No’ eg. Are you Mr.Vinod. 4. After drawing the sample(s), label the tubes before leaving the patient. • Labeling samples away from the patient greatly increases the risk of mislabeling. 5. Document that you drew the blood sample. Never sign for anyone else’s work! 6. If any discrepancies are discovered they must be satisfactorily resolved prior to collecting a pre-transfusion sample. ALERT Errors in sample labelling and patient identification are the leading cause of Acute Hemolytic Transfusion Reactions – a potentially fatal complication of transfusions. If one unit of blood is intended, a 3-5 ml sample in PLAIN vial and 2 ml in EDTA vial should be collected. For every additional unit 1 ml more blood in plain vial should be sent. Note: - From neonates and very anemic patients only EDTA sample may suffice . For double volume exchange transfusion (DVET) 3 ml mother’s sample in plain vial alongwith neonatal EDTA sample is required.
  11. 11. 11 1. The sample vial must be labeled with gum pasted paper only and other forms of labels, such as, leucoplast pasted labels will not be accepted. 2. Requisition form should be filled properly showing clinical diagnosis, indication for transfusion along with pretransfusion Hb. (platelet count, APTT/PT/PTI in case of blood components), time and date for cross- matching. 3. Resident’s signature along with full name and designation should be written on the form. 4. In case of previous transfusion, complete the reaction form and attach it with the current request for cross match. 5. Tick the appropriate option for cross-matching i.e., blood if required for planned hemotherapy or elective surgery (*routine cross-matching including AHG testing), or urgently (*Urgent cross-matching/Immediate spin cross-matching). 6. All cases for routine cross-matching should be sent 24 hours in advance and incase of rare blood groups, please discuss with the cross-matching resident at least 72 hours prior to the planned surgery. 7. Routine samples are received upto 2:30PM on Monday to Friday and 11:00AM on Saturdays. After this specified time, blood samples are accepted in emergency only, where immediate spin cross-matching technique is done. 8. For all routine cases, blood donation slips are to be sent along with the requisition form. In case no donors are available, please discuss well in advance with the resident on cross match duty. 9. Only those cases in which blood is required to be transfused immediately should be marked “URGENT” or “IMMEDIATE”. 10.Cross-matched blood will be stored in the Dept. of Transfusion Medicine for a period of 3 days from the date of cross-match. This date can be extended only to 7 days after request from physician/surgeon in-charge and he/she should specify time period to reserve the unit(s). In the absence of information from the attending doctors, these cross-matched units will be received back and utilized for other patients to avoid wastage and outdating of units.
  12. 12. 12 1.4 Process flow from receiving a requisition at Dept. of Transfusion Medicine till issue of blood. The time line. 1. Blood requisition is received at Dept. of Transfusion Medicine reception. Following points are checked before accepting blood requisition a. Name and CR No. of patient on requisition form and sample should match precisely. b. Requisition form is appropriately filled and signed by the resident. c. Quantity of blood sample is adequate for blood grouping and crossmatching. Blood requisition details are entered in blood issue register and DTM requisition number is issued to the patient’s attendant on a “Patient’s Identification slip’’. Time Taken during this process is 5 minutes. 2. After receiving the requisition sample is subjected to preliminary ABO and Rh typing so as to ensure that ABO and Rh matched blood is available in the current blood inventory. Time taken during this process is 15 minutes.
  13. 13. 13 3. If ABO and Rh matched blood is available in the inventory, crossmatching technique is decided, either Immediate spin (Is) or Antihuman globulin phase (AHG) depending on the requisition by the clinician as urgent or routine. This is a decision making point for type of technique. Hence all residents must understand the merits and demerits of urgent vs routine blood requisition. 4. Crossmatching a. Immediate spin crossmatch (Is) i. Repeat blood group of patient. ii. Repeat blood group of donor unit. iii. Major crossmatch is performed by using donor red cells and patient plasma with tube technique. iv. Tube is examined for any agglutination or haemolysis. Time taken during this process is 30 minutes. 5. AHG phase crossmatch i. Tube of immediate spin crossmatch is incubated in a 37o C water bath for 90 minutes. ii. After incubation RBC are washed 3 times with normal saline to remove unbound antibodies. iii. After washing two drops of AHG(anti human globulin reagent) is added and tube is centrifuged and examined for any agglutination. iv. If non-reactive, check cells are added to validate the test. Time taken during this process is 2 hours and 30 minutes. 6. Documentation of results of crossmatch on the requisition form and crossmatch register. Preparation of “blood bag compatibility label” and “compatibility form’’ (reaction form) with details of intended recipient of the blood bag. Time taken during this process is 10 minutes. 7. Issue of blood bag from Dept. of Transfusion Medicine reception a. “Patient’s Identification slip” filled and signed by clinician is received at the counter. b. If the crossmatch has been performed compatibility report is available at Dept. of Transfusion Medicine reception. Name and CR No. of patient is matched on “Patient’s Identification slip” and compatibility report.
  14. 14. 14 c. Blood units are taken out from refrigerator according to compatibility report. d. Blood bag front and back label and compatibility report is matched for Name, CR No. and blood group of patient and blood bag. e. Blood bag is checked for any abnormal appearance like leakage ,hemolysis, gas formation or discoloration. f. Blood bag is issued after entering details of blood bag in issue register and taking receiving from patients attendants. Time taken during this process is 5 to 10 minutes. Note: we process requisitions in batches for optimum quality control. However in life saving situations even single requests are processed. Collective time from requisition to issue of blood for Immediate spin crossmatch (Urgent crossmatch) is 1 hour 30 minutes and for AHG crossmatch( Routine Crossmatch) is 4 hours. Urgent(Immediate spin) vs. routine cross-matching testing Immediate spin cross-matching Routine cross-matching including AHG testing Designed to detect compatibility of IgM type of antibodies in patient’s serum against antigen on donor’s red cells in saline phase i.e., ABO compatibility testing In addition to saline phase compatibility testing (IgM antibodies detection), AHG testing is designed to detect compatibility of IgG type of antibodies in patient’s serum against antigen on donor’s red cells Also detect anti-Lea , - Leb , -I, -P1, -M and N but not some other clinically significant antibodies. AHG testing detects anti-D, -C, -E, -c, -e, -K, - Jk, -Fy, -S, -s, - Lea and Leb hence most of the clinically significant antibodies are detected. Note: - For any queries contact the resident on cross-match duty. JR on Call: 9914209480, SR on Call: 9914209486
  15. 15. 15 1.5 Blood request in extreme emergency ( Life threatening bleed) 1. Group Specific Uncrossmatched Blood When pre-transfusion sample is available. Blood can issued within 15 minutes after blood grouping of patient and blood bag and later crossmatch can be completed . 2. Emergency O Rh (D) Negative Uncrossmatched Blood Extreme emergencies, when there is no time to obtain and test a sample,“O Negative PRBC” if not available “O Positive PRBC” can be issued within minutes. (Only after consent from clinician as a life-saving measure) On these occasions, the requesting clinician must take full responsibility for the use of uncrossmatched blood, which carries a significant risk of severe transfusion reaction and should therefore be restricted to life threatening emergencies. The reason must be documented in the medical record.
  16. 16. 16 1.6 Single Donor Apheresis Platelet (SDAP) Requisition Guidelines Requisition for SDAP- 1. Requisition should be sent to the Apheresis section of the Department of Transfusion Medicine on requisition form for blood components. 2. Send 2 ml EDTA sample of the patient along with requisition form and indication for transfusion with platelet count should be mentioned on the form with signature, name and phone no. of requesting clinical JR/SR. 3. Send 3-4 healthy donors having same blood group as that of patient along with requisition form to apheresis section. 4. Separate requisition forms should be sent in case two SDAP units are required for the same patient. General SDAP Donor selection Criteria- 1. Donor should be in good health, physically fit and mentally alert. 2. Donor should be 18-60 year of age. 3. Donor should be of the same blood group. 4. Donor should not be first degree relative of the patient, 5. Donor should be more than 60 kg of weight, 6. Donor should have Hb more than 12.5 g/dl, 7. Donor should have platelet count ≥1.5 x 103 /µl. 8. Donor should not have taken NSAIDs/ Antibiotics in last 72 hrs. Procedure related Cost 1. Ensure about the affordability of patients attend of SDAP procedure, disposable kit needed for SDAP procedure cost around Rs. 7000 to 8000. 2. A new disposable kits is required for each procedure. 3. Donor screening charges Rs 550.(Blood grouping and mandatory infectious disease testing)
  17. 17. 17 Time involved in the SDAP Procedure- 4 to 4.30 hours (on an average) Storage- Recommended Storage temperature for SDAP is 20-24o C in a platelet incubator and agitator. Shelf Life- 5 days All platelet products (SDAP/RDP) should be transfused as and when they are issued and received by patient bedside after proper identification of patient. NEVER KEEP THE PLATELET COMPONENTS IN REFRIGERATOR 5 minutes 15 minutes 45-60 minutes 30 minutes 1-2 hours 10 minutes 30 minutes 10-15 minutes
  18. 18. 18 1.7 Blood Components can be transfused across ABO and Rh blood groups, when group specific blood component is not available next compatible available group component can be safely transfused as shown in Table 4. Table 4: Compatibility Chart for blood components Patient Blood Group Compatible donor blood group Red Blood Cells Platelets Plasma/ Cryosupernatant Plasma Cryoprecipitate O Positive O Positive O Negative Rh Positive or Negative O preferred Any Group Any Group O Negative O Negative Rh Negative O preferred Any Group Any Group A Positive A Positive A Negative O Positive O Negative Rh Positive or Negative A preferred A, AB Any Group A Negative A Negative O Negative Rh Negative A preferred A, AB Any Group B Positive B Positive B Negative O Positive O Negative Rh Positive or Negative B preferred B, AB Any Group B Negative B Negative O Negative Rh Negative B preferred B, AB Any Group AB Positive Any Group Positive/Negative Rh Positive or Negative AB preferred AB Any Group AB Negative Any Group Negative Rh Negative AB preferred AB Any Group Note: Whole blood is always transfused blood group specific.
  19. 19. 19 1.8 Preparing the patient for transfusion: Determine if your patient has had any problems or reactions with previous transfusions. If so premedication may be required. Indication Premedication History of repeated allergic reactions Antihistamine and/or Steroid History of repeated febrile reactions Antipyretic Determine the correct IV access required for transfusion Blood Product Rate of infusion IV Access Red blood Cells Rapid Transfusion in adults 16 to 18 G (Gauge) Red blood Cells Routine Transfusion in adults 20 to 22 G Other blood products Any size Paediatrics 22 to 25 G Transfusing rapidly and under pressure through too small an IV access can cause hemolysis of red blood cells. Ensure that the IV access is dedicated to the transfusion. Blood products must not come in contact with medications or incompatible solutions (e.g. 5% Dextrose, hydroxyethyl starch, Ringer Lactate). When transfusing through a central line with multiple lumens, medications/solutions can be infused through other lumens without damaging the blood product. IV pumps, blood warmers, and rapid infusers must be suitable for transfusion and do not damage the blood product. Do not use devices that have not been approved for use with blood products.
  20. 20. 20 1.9 Need for warming of blood before transfusion There is no need of warming of blood in elective transfusion where a unit of blood is transfused over 2 to 4 hours. However, warming of blood can be useful when rapid transfusion of components is required, especially in trauma or surgery settings, because the infusion of cold components can cause hypothermia and cardiac complications, increasing morbidity and mortality for the patient. Warmed blood is most commonly required in: a) Large volume rapid transfusions: — Adults: greater than 50 ml/kg/hour — Children: greater than 15 ml/kg/hour b) Transfusions to neonates c) Exchange transfusion in infants d) Patients with clinically significant cold agglutinins. Blood should not be warmed by placing it in a microwave, on a heat source, or in hot water or by using other devices not specifically approved for blood warming. Blood should only be warmed in a blood warmer. Blood warmers should have a visible thermometer and an audible warning alarm and should be properly maintained. Blood should never be warmed in a bowl of hot water as this could lead to haemolysis of the red cells which could be life-threatening.
  21. 21. 21 1.10 Blood Transfusion Set (BT Set) The following blood products must be transfused through blood tubing containing a 170 micron filter to capture any fibrin debris: Red blood cells, platelets, plasma, cryosupernatant plasma and cryoprecipitate. BT Set must be changed after every 2-4 units and at least 12-hourly during blood component transfusion. Note that: Platelets are best transfused through blood tubing not previously used for red cells. Platelets will adhere to fibrin captured in the filter. Used blood tubing can be a breeding ground for bacteria. Do not leave it attached to the patient. ALERT Blood transfusion set is required for transfusion of blood products and must be changed at prescribed intervals to decrease risk of bacterial sepsis. Do not store blood units in freezer compartment or chill tray of the refrigerator. Red cells will hemolyse. Do not refrigerate platelets. They become non-viable.
  22. 22. 22 1.11 Final check before transfusion Visually check the blood unit for clots, unusual colour, and any leaks. Completely hemolysed packed red blood cell unit can be recognised by change in colour from red to black. In case of any doubt you can get blood units checked from Dept. of Transfusion Medicine staff before transfusion. Check the expiration date on the blood bag label (Annexure 2) . Check the transfusion order and verify that consent was obtained. Patient and blood unit identity Check 1. Ask the patient to identify himself/herself by family name. If the patient is unconscious, ask a relative or a second member of staff to state the patient’s identity. 2. Check that the following details on the compatibility label attached to the blood bag exactly match the details on the patient’s file: • Patient’s family name and given name • Patient’s central registration number (CR NO.) • Patient’s ward or operating room • Patient’s blood group. 3. Check that there are no discrepancies between the ABO and RhD group on: • Blood bag Label ( front Label) • Compatibility label ( Back Label) • Compatibility report (Reaction form) 5 Check that there are no discrepancies between the donation number on: • Blood bag • Compatibility label. • Compatibility report (Reaction form) • If you find any discrepancy do not proceed. Contact the Dept. of Transfusion Medicine immediately ___________________________________________________________________ ALERT: Checking blood immediately prior to the transfusion is the LAST opportunity to catch any errors.
  23. 23. 23 2 Transfusion Phase 2.1 Starting and monitoring blood transfusion Before starting blood: Record baseline vital signs and assessment before starting each unit: Temperature Blood pressure Pulse Respiration Oxygen saturation if available Auscultation for patients at risk for overload (elderly, pediatric, cardiovascular disease) After starting blood: 1. For the first 15 minutes: Start initially with a slow rate unless transfusion is extremely urgent. Monitor your patient closely. 2. After the first 15 minutes: Reassess your patient and repeat vital signs. Increase flow to prescribed rate if no reaction observed. Monitor the patient At least every hour during transfusion On completion of the transfusion 4 hours after completing the transfusion If there is suspected reaction ALERT Start blood with caution as serious reactions can present early in the transfusion. Some patients are at greater risk for circulatory overload – transfuse more slowly.
  24. 24. 24 Repeat monitoring with each subsequent unit. Repeat vital signs more often for patients: At greater risk for circulatory overload (elderly, pediatric, cardiovascular disease). Who have experienced previous reactions. Who are unstable. When possible, instruct your patient to notify you if they experience: Hives or itching. Feeling feverish or chills. Difficulty breathing. Back pain or pain at the infusion site. Any feeling different from usual. ALERT Patients must be appropriately monitored to detect transfusion reactions as soon as possible
  25. 25. 25 2.2 Documentation of Transfusion The record you make in the patient’s case-notes is your best protection if there is any medico-legal challenge later on. The record should include: . 1. Whether the patient and/or relatives have been informed about the proposed transfusion treatment. 2. The reason for transfusion. 3. Signature of the prescribing clinician. 4. Pre-transfusion checks of: Patient’s identity Blood pack Compatibility label Signature of the person performing the pre-transfusion identity check. 5. The transfusion: Type and volume of each product transfused Unique donation number of each unit transfused Blood group of each unit transfused Time at which the transfusion of each unit commenced Signature of the person administering the blood component Monitoring of the patient before, during and after the transfusion. 6. Any transfusion reactions. Documentation can be done in transfusion sheet ( Annexure 3)
  26. 26. 26 2.3 Transfusion reactions Recognizing acute transfusion reactions Acute reactions usually occur during or up to 24 hours following the end of a transfusion and may present with signs and symptoms given in Table: 5. Table 5: Acute Transfusion Reactions Type of Reaction Clinical Signs and Symptoms 1. Hemolytic transfusion reaction Fever/chills, hypotension/tachycardia, cola coloured urine, nausea, vomiting, pain in flanks/back/abdomen/chest etc. 2. Bacterial contamination Fever, chills, hypotension, nausea, vomiting, dyspnoea and diarrhoea. 3.Transfusion related acute lung injury (TRALI) Dyspnoea or cyanosis, fever, tachycardia, hypotension 4.Febrile non hemolytic transfusion reaction (FNHTR) Fever, chills, rigors, cold, headache, nausea, vomiting 5.Allergic/anaphylactic reaction Pruritis, urticaria, flushing, angioedema, hoarseness, stridor, wheezing, chest tightness, dyspnoea, cyanosis, anxiety, nausea, vomiting, abdominal cramps and diarrhoea. Note: Signs and symptoms of various acute transfusion reactions often overlap; hence, complete workup is necessary.
  27. 27. 27 Transfusion Reaction management and investigation Suspected reaction management: 1. Stop the transfusion immediately. 2. Maintain IV access for treatment if necessary but do not flush the blood tubing 3. Check vital signs 4. Take necessary resuscitative measures to stabilize the patient. 5. Verify that patient ID matches the compatibility label and compatibility report. 6. Verify that the blood unit number matches the compatibility label and compatibility report (Annexure: 2). 7. Notify the physician but remain with the patient. 8. Notify the Dept. of Transfusion Medicine of the reaction. Send the following to the Department of Transfusion Medicine: i) Blood bag with BT set ii) Post transfusion samples • 2 ml EDTA sample. • 3 ml plain vial sample. iii) Completely filled and signed reaction form indicating signs/symptoms of reactions) In case of suspected bacterial contamination: Send cultures both from the patient as well as blood bag at the bedside immediately. Please return un-utilized blood bag in fully preserved condition as soon as possible to the Deptt. of Transfusion Medicine (ideally within 2 hours of issue).
  28. 28. 28 Following investigation should be done: as per symptoms in transfusion reaction. Complete hemogram Plasma hemoglobin Coagulation profile Bilirubin (Unconjugated/conjugated) Urea Creatinine Serum electrolytes Next voided urine for hemoglobin testing: Monitor urine output if hemolysis suspected Chest X-Ray if patient has new respiratory symptoms Blood cultures from the patient: • Drawn from a different vein • Antibiotics should be started immediately if bacterial sepsis suspected. Transfusion Reaction must be reported immediately to the Department of Transfusion Medicine as some time this can prevent companion transfusion reaction. 2.4Hemovigilance This is set of surveillance procedures, from the collection of blood and its components to the follow up of recipients to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent their occurrence or recurrence. National Hemovigilance program of India was launched in December 2012 by National institute of biological (NIB), Noida, Ministry of health and family welfare Govt. of India. The major aim of the program is to track adverse events related to blood transfusion and help to identify trends and recommend best practices and interventions required to improve blood safety in the country. Department of Transfusion Medicine, PGIMER Chandigarh is actively participating in the program. All the clinical colleagues are requested to kindly participate in the program by reporting all transfusion reaction related to blood transfusion so as to increase transfusion safety in our institute and in our country.
  29. 29. 29 Annexure: 1 Post Graduate Institute of Medical Education and Research CONSENT FORM FOR THE TRANSFUSION OF BLOOD / BLOOD COMPONENTS Patient Name ______________CR. Number_________________ Ward/Bed No._______________ Blood transfusion is a life saving medical procedure. Blood can be given as “whole blood” or as components such as: Red cells, Platelets, Plasma and Cryoprecipitate. 1. I /My patient have been informed of the transfusion options available and expected benefits of transfusion of blood and / or components. 2. I /My patient agree to the administration of blood and / or components in the interest of proper medical care. 3. I /My patient understand that blood / blood components to be administered have been prepared and tested in accordance with rules established by National Regulation. However, there is still a very small chance that an adverse reaction can occur such as: fever with or without chills and rigor, itching and hives, which are treatable. Rarely an unpredictable life threatening event can also occur. 4. I/My patient have been informed that despite mandatory screening for blood borne infections such as HIV, Hepatitis B, Hepatitis C, Syphilis and Malaria, the risk of acquiring these infections is not totally eliminated. 5. I/My patient have had the opportunity to ask questions about transfusions, alternatives to transfusion, risk of not transfusing, the procedures to be used and the relative risks and hazards involved. 6. I/My patient believe that I have been sufficiently informed to make a decision to give a consent for transfusion of blood / blood components. 7. I/My patient have been informed and explained the above in a language that I/my patient understand. AUTHORIZATION BY PATIENT Signature/Thumb impression_______________ Signature/Thumb impression:___________ Name of the Patient______________________ Name of Witness:_____________________ Date__________________ Doctor _______________________ Designation_____________________ PATIENT’S ATTENDANT/NEXT OF KIN The patient is unable to give consent because _____________________________________ And I_________________________________________(name / relationship to patient), therefore consent for the patient. I acknowledge that I have had an opportunity to discuss this procedure, as stated above, with my physician, physician designee and hereby consent to this procedure. Signature/Thumb impression_______________ Signature/Thumb impression:___________ Name of the Patient attendant/Next of kin________________ Name of Witness:________ Date:____________ Doctor____________________ Designation_________________
  30. 30. 30 Annexure: 2 Blood Bag label To be completed and sent back to Dept. Of Transfusion Medicine With next requisition To be retained in patient’s file To be retained in patient’s file Compatibility Report Compatibility Label
  31. 31. 31 Annexure: 3 Post Graduate Institute of Medical Education and Research Blood Transfusion Sheet Patient’s Name ________________________________CR No.____________________________________ Age /Sex__________ Patient’s Blood Group_____________ Blood Bag Number Blood group and Type of Blood component Vitals before starting Transfusion Transfusion Starting Time and Date Vital 15 min after of starting transfusion Transfusion End Time and Date Vitals at The end of Transfusion Name and Signature of person Transfusing and counter checking Remarks/Transfusion Reaction 1st Blood Bag Temp: PR: BP: RR Temp: PR: BP: RR Temp: PR: BP: RR 2nd Blood Bag Temp: PR: BP: RR Temp: PR: BP: RR Temp: PR: BP: RR 3rd Blood Bag Temp: PR: BP: RR Temp: PR: BP: RR Temp: PR: BP: RR 4th Blood Bag Temp: PR: BP: RR Temp: PR: BP: RR Temp: PR: BP: RR 5th Blood Bag Temp: PR: BP: RR Temp: PR: BP: RR Temp: PR: BP: RR
  32. 32. 32 Annexure : 4 Department of Transfusion Medicine, PGIMER, Chandigarh Flow for arrangement of Intrauterine Transfusion (IUT) Blood unit Requisition Preparation of IUT blood unit Issue of unit Post-IUT Assessment Inform Senior Resident (9914209486) about IUT procedure at least two days in advance Ask patient’s attendants to arrange for blood donor (preferably O Negative) Send the properly labelled patient requisition form and blood sample for IUT along with relevant clinical history: Rh clinic number, ICT status and titer levels (if known), previous IUT details Extended Rh phenotyping and other minor antigen typing, if indicated in the mother, of the available O Negative blood units is performed If phenotype matches, cross matching is performed If cross match is compatible, the blood unit is reserved and then OBG SR/JR to confirm the date and time of IUT to SR Transfusion Medicine Blood unit is sent to Component preparation Lab for preparation of IUT bag 3-5 hours* 2-3 hours* 2-3 hours* When IUT blood unit is ready, it is issued along with Reaction form after receiving properly filled Identification (ID) Slip of the patient Send the pre-IUT and post-IUT samples and give the feedback of the IUT procedure to SR Transfusion Medicine *The time lines are indicative only, it may take even more time in patients with multiple alloantibodies and during shortage of O Negative units.