Blood Transfusion Essentials

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Blood Transfusion Essentials
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Topics

• ABO Blood Group compatibility
• Rh Blood Group compatibility
• Other blood group systems
• Rules for patient identification
• Blood administration
• Transfusion Reactions
• Other products

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ABO Blood group Compatibility

• The A and B antigens are glycoproteins on the red
  cell surface
• The O blood group results from an absence of
  these antigens
• Everyone has antibodies to the antigen they do
  not possesseven if they have never been exposed
  to these antigens by transfusion or pregnancy.
  They are naturally occurring. These antibodies
  are predominantly IgM.

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ABO Blood group compatibility

• When red cells with these antigens are transfused
  to a person with the corresponding antibody
• The antibody attaches to the red cells,
  Complement enzymes are attached and the red cell
  bursts within the circulation (intravascular
  hemolysis)
• Free hemoglobin and red cell stroma contributes
  to
• Hypoentensive shock, renal failure and DEATH

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Acute Hemolytic Reaction
Adonor red cells
IgM anti A
B
C1-9 activation
Coagulation activation cytokine
release neuroendocrine response
Membrane lysis
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Rh blood group compatibility

• Rh antigens are protein antigens on red cells
• Rh D ? main Rh antigen
• Other Rh antigens are C,c,E,e
• Antibodies to Rh antigens only form if an
  individual is exposed to antigens they do not
  possess (immune antibodies not naturally
  occurring and usually IgG)
• Exposure to red cell antigens occurs following
  transfusion or pregnancy

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Rh blood group compatibility

• When Rh positive red cells are transfused to an
  individual without Rh antibodiesno hemolysis
  occurs but antibody development may begin
• When they are transfused to a person with Rh
  antibodies, the antibodies coat the red cells but
  Complement enzymes are not bound to the cells
• The antibody coated cells are gradually removed
  by cells in the spleen and liver (extravascular
  hemolysis)
• This is called a delayed hemolytic transfusion
  reaction

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Rh Blood group compatibility

• Although a person must have an exposure by
  transfusion or pregnancy in order to develop anti
  Rh antibodies (like anti D), about 80 of those
  exposed will develop antibodies the D antigen is
  highly immunogenic
• Anti D is important to avoid in women who may
  become pregnant since it can cross the placenta
  and cause HDN (hemolytic disease of the newborn)
• Anti D is prevented by the administration of RhIg
  (WinRho) ? passive anti D

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Rh Blood Group Compatibility

• We try to avoid giving Rh (D antigen ) red
  cells to children or women of child bearing age
• We sometimes give men or older women Rh (D)
  red cells to try and preserve our Rh negative
  stock
• Once someone has developed an anti D we must give
  them D negative units thereafter

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Other Blood Group Systems

• There are other blood group systems which are
  also clinically significant with regard to blood
  transfusion
• An antibody screen involves testing patient
  plasma against these known antigens to detect any
  clinically significant antibodies that may have
  developed from previous exposure to foreign
  antigens through transfusion or pregnancy

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Other Blood Group Systems

• We may detect antibodies to any of the following
  antigens

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The rules for patient identification -
pretransfusion

• At the time of pre transfusion blood collection
  a patient must be identified by two individuals
• the identifier confirms that the patient first
  and last name and phn are the same on the patient
  id band and on the requisition, then signs the
  requisition
• The specimen is collected into 2 EDTA tubes
• The blood tubes must be labeled after collection
  at the bedside, with first and last name and phn,
  exactly matching the requisition
• The date and time of collection are recorded on
  the requisition

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The rules for patient identification

• A BBIN wrist band must be attached and the same
  BBIN affixed to the properly labeled requisition
  and the blood tubes
• The requisition must be signed by the individual
  collecting the blood sample
• The blood samples and requisition must be
  received together in the blood bank

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Tube Labeling

• Just a little note from Blood Bank to the
  labelers?
• Please try to place labels on the tubes
  vertically with the name reading from the lid
  down
• There is room for the BBIN number to the right
  of, or below the patient healthcare number

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Ready to transfuse

• Before the blood is picked up the orders to
  transfuse should be confirmed
• The component type should be checked and patient
  consent confirmed
• The patient name in writing or on a patient id
  label should be provided to the blood bank at the
  time of pick up phn is also required along with
  product type
• The technologist will ask you to spell back the
  patient name and phn from the blood tag while
  checking these identifiers on the patient id label

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The rules for patient identification at
transfusion

• When a blood component is received, it should be
  taken directly to the bedside of the patient for
  whom transfusion is planned
• The blood tag identifiers, name, phn and BBIN
  should be compared to the patient id wristband
• The blood tag blood group should be compared to
  the blood bag label blood group
• The donor unit number on the blood tag and the
  blood bag must agree
• Two signatures are required on the tag to confirm
  the identification procedure

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Ready to transfuse

• Remember
• Once picked up the blood should be infusing
  within 30 minutes
• Blood products should not be stored in any
  on-unit refrigerators
• Blood products should be completely infused
  within 4 hours to avoid the possibility of
  bacterial growth in the unit

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Monitoring the transfusion

• Vital signs should be taken pre transfusion and
  recorded in the chart
• Repeat vital signs at 15 minutes and then at
  least once during the remainder of the
  transfusion
• Consider more frequent VS for unstable patients
  or those for whom some blood group
  incompatibility may be present
• Blood tag will be labeled transfuse with
  caution in these circumstances

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Blood administration

• Standard blood IV set 18 gauge catheter if
  possible
• Y connector to Saline for blood components
• Certain types of IVIG must be run with D5W
• Review package inserts for specific instructions
• Standard blood filter required
• Other filters optional and not recommended

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Blood administration

• Filter types include
• microaggregate filters (40 micron) which may
  hinder rapid infusion
• Leukodepletion filters rarely used at bedside
  now because all units are filtered for leukocytes
  prior to storage by CBS
• Standard blood filters which should be used
  with all transfusions

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Blood administration

• ICU, Emergency, and the OR may use rapid infusers
  and blood warmers during infusion
• These devices should be regularly checked for
  maximum temperature (40?C) and maximum pressure (
  300 mm Hg)

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Blood administration

• Rate should be specified by ordering physician
• No greater than 4 hours per unit of red cells
• For patients in whom volume overload is of
  concern, the unit may be split in the blood bank
  upon request and each half unit transfused over 4
  hours

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Blood administration

• Units of cryoprecipitate are usually infused
  rapidly and flushed with saline
• Due to their small volume, flushing is required
  to maximize product usage

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New Blood Bag Information

• Blood bag manufacturer for CBS has changed to
  MacoPharma (red cells) and Baxter (platelet
  pools)
• New spiking procedure
• Tear port protector tabs sideways away from the
  port
• Hold tabs down and insert the spike of the
  infusion set with a steady rotational motion
• New Baxter bags for Buffy Coat pooled platelets
  have easy twist off port covers
• Ensure the spike is inserted just far enough to
  pierce the septum

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New Blood Bag Information

• www.cha.ab.ca
• Choose information for health professionals then
  lab medicine and pathology on side bar
• Scroll down and select more information
• Scroll down and select transfusion medicine
• Select new blood bag information presentation
• Select information training video

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How long does it take?

• O negative unmatched stock always available
• 5 10 minutes
• Crossmatched blood no antibodies detected
• 1 hour
• Crossmatched blood simple antibodies
• 2 hours
• Crossmatched blood complex antibodies
• 2 hours to 2 days

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No time for a crossmatch!

• O negative is given as the universal donor group
  for red cells
• AB is given as the universal donor group for
  plasma

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Transfusion reactions

• Fever
• Chills
• Itching
• Shortness of breath
• Chest tightness
• Pain at infusion site

• Hypotension
• Hypertension
• Tachypnea
• Tachycardia
• Rash
• Red or dark urine

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Transfusion Reactions

• Any new symptom or sign during or following
  transfusion of a blood component or fractionation
  product

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What to do?

• STOP the transfusion
• Maintain the IV with NS keep the blood product
  and attached tubing
• Do a clerical check (right blood to patient?)
• Determine vital signs and contact medical staff
• Notify the blood bank
• Collect a post transfusion sample and document
  reaction symptoms and signs on the blood tag
• Send remnants of component with the post
  transfusion sample, the tag, and a transfusion
  service requisition to the blood bank

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Can you give more blood?

• It depends
• Status of the patient
• interpretation of the reaction
• Let the blood bank know if more blood is required
  immediately

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Other products
platelets plasma cryoprecipitate
IVIG RHIG Albumin
Other immunoglobulin fractions Coagulation factor concentrates pentaspan
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Other products

• For products other than red cells we need to know
  the blood group but we dont perform a crossmatch
• Often we will need a sample to confirm the blood
  group
• Patient must still be wearing BBIN wristband

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Why do we need to re-match every 3 days?

• Red cell exposure leads to possible antibody
  development
• Antibodies may start to form or increase in
  amount within 3 days
• After the 3 days, in a person who has been or may
  have been transfused, we need to re check to make
  sure no antibodies are present before issuing
  more blood
• Pregnancy is also a potential means of red cell
  exposure and antibody development

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Resources

• Call the blood bank!
• Blood bank staff
• Blood bank specialist
• Hematopathologist on call
• Clinical Guide to transfusion
• www.cha.ab.ca
• Choose information for health professionals then
  lab medicine and pathology on side bar
• Scroll down and select more information
• Scroll down and select transfusion medicine
• Select guide to blood transfusion

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Questions?
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Question 1

• Two signatures are required on a blood bank
  requisition because?

• Patient misidentification is the leading cause of
  transfusion related death

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Question 2

• A group A red cell unit may be given to a group O
  patient.
• NO!

• A group O red cell unit may be given to a group A
  patient.
• YES!

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Question 3

• Rh negative red cells may be given to an Rh
  positive patient.
• YES

• Rh positive red cells may be given to an Rh
  negative patient.
• Sometimes

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Question 4

• What is the first thing you do when you think a
  patient may be experiencing a transfusion
  reaction?
• STOP the transfusion

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Question 5

• Why must an inpatient be re-crossmatched every 3
  days if they require more packed cells?
• To check for recent antibody development

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End