Blood Transfusion Guidelines in Clinical Practice

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Blood Transfusion Guidelines in Clinical Practice

• Salwa Hindawi
• MSc, FRCPath, CTM
• Medical Director of Blood Transfusion Services
• KAUH
• 
  26th July2008

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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

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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
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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
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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
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Principles of Clinical Transfusion Practices

• Avoid blood transfusion
• Transfusion is only one part of the
  patients 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.

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• 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

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• 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.

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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

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• WHEN WE SHOULD TRANSFUSE BLOOD ?WHAT BLOOD
  COMPONENT
• SHOULD BE TRANSFUSED ?

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TO TRANSFUSE BLOOD WHEN NECESSARY
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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

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• 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,19962001. Williamson LM.
Transfusion Trigger in the UK. Vox sang 2002.
AABB Technical Manual 14th
ed, 2002.
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Administration of blood components

• Pretransfusion
• Recipient identification The name and
  identification number on the patients
  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.

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Guidelines for blood component therapy
Guidelines for blood component therapy
Indications NB Hb should not be the sole deciding factor for transfusion. Haemoglobin (Hb) trigger for transfusion
If there are signs or symptoms of impaired oxygen transport 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 lt 7 g/dL
Preoperative and for surgery associated with major blood loss. lt 7 8 g/dL
In a patient on chronic transfusion regimen or during marrow suppressive therapy. May be appropriate to control anaemia-related symptoms. lt 9 g/dL
Not likely to be appropriate unless there are specific indications. Acute blood loss gt30-40 of total blood volume. lt 10 g/dL
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Guidelines for Transfusion of RBCs in Patients Less than 4 Months of Age
1. Hemoglobin lt7 g/dL with low reticulocyte count and symptoms of anemia
2. Hemoglobin lt10 g/dL with an infant
On lt35 hood O2 On O2 by nasal cannula On continuous positive airway pressure (CPAP)/intermittent mandatory ventilation (IMV) with mechanical ventilation with mean airway pressure lt6 cm H2O Significant apnea or bradycardia Significant tachycardia or tachypnea Low weight gain
3. Hemoglobin lt12 g/dL with an infant
On gt35 hood O2 On CPAP/IMV with mean airway pressure ?6 to 8 cm H2O
4. Hemoglobin lt15 g/dL with an infant
On extracorporeal membrane oxygenation (ECMO) Congenital cyanotic heart disease
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Indications Platelet Count trigger for transfusion
As prophylaxis in bone marrow failure. lt 10 x 109/L
Bone marrow failure in presence of additional risk factors fever, antibiotics, evidence of systemic haemostatic failure. lt 20 x 109/L
Massive haemorrhage or transfusion. In patients undergoing surgery or invasive procedures. Diffuse microvascular bleeding-DIC lt 50 x 109/L
Brain or eye surgery. lt 100 x 109/L
Appropriate when thrombocytopenia is considered a major contributory factor. Any Bleeding Patient
In inherited or acquired qualitative platelete function disorders, depending on clinical features setting. Any platelet count
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Indications FFP trigger for transfusion
Multiple coagulation deficiencies associated with acute DIC. Inherited deficiencies of coagulation inhibitors in patients undergoing high-risk 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 life-threatening 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 PT PTT are more than 1.5 times the upper limit of normal range
Indications Cryoprecipitate trigger for transfusion
Congenital or acquired fibrinogen deficiency including DIC. Hemophilia A, von Willebrand disease (if the concentrate is not available). Factor XIII deficiency. Fibrinogenlt 1gm/L
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transfusion dependent patients Bone marrow transplant candidates either autologous / peripheral blood stem cell transplants (PBSCT) or allogeneic bone marrow transplants may be for Patients undergoing intensive chemotherapy regimens Previous repeated febrile reactions to red blood cells Guidelines for routine blood leucodepletion
Intrauterine transfusion (IUT) and neonates received IUT. One week prior to stem cell collection, and for 12 months post autografting or allografting. Hodgkins disease Treatment with purine analogues (fludarabine, 2-CdA, deoxycofomycin) Aplastic anaemia within 6 months of ATG treatment Products obtained from close relatives or HLA matched donors. Immunodeficiency patients congenital or acquired Guidelines for blood Irradiation (to prevent TAGVHD)
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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, CT ratio is 11 .
• An acceptable value is 31 - 21 which
  corresponds to a blood usage of 30-50.

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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

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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.

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Crossmatch to Transfusion ratio (CT ratio)

• blood is used more efficiently when the number of
  units set aside for a particular patient
  (crossmatched) are actually transfused.
• CT ratio is less than 21
• when a patient does not need blood, it is good
  practice to get a T S but not a T C

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Incompatible Blood TransfusionClinical
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.
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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
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• 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.

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• 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.

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• 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.

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• 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.

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Complications of Blood Transfusion

• Immediate Delayed
• HTR GVHD
• FNTR PTP
• TRALI Iron
  overload
• Bacterial
  Infectious
• contamination diseases
• Allergic, Anaphylaxis

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TRANSFUSION REACTION WORK-UP FORM
This part should be filled by the physician
incharge
Date /time _________________________ Patient's name_____________________
Ward _____________________________ File number ______________________
Number of Pregnancies/deliveries ________________ Number of previous transfusions_______________
Diagnosis _______________________________________________________________________________ ________________________________________________________________________________________ Diagnosis _______________________________________________________________________________ ________________________________________________________________________________________
Transfusion time discontinued Transfusion date/time started
Temp discontinued Temp started
Reaction noted put ? if indicated and please
specify time reaction started and duration
?Pruritus ?Hematuria ?Anxiety ?Chest Pain
?Pain in legs ?Oliguria ?Restlessness ?Chills
?Pain in back ?Anuria ?Headache ?Fever
?Rigor ?Jaundice ?Urticaria ?Sweating
?Bronchospasm ?Shock ?Pallor ?Nausea
?Dyspnea ?Cyanosis ?Erythema ?Vomiting
?Pulmonary edema ?Pulmonary edema ?Precordial distress ?Precordial distress
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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 ? ____________________________
_______ Patients sample and donor unit are
correctly identified. ? Yes ? No Amount of
blood was transfused unit ___________
volume ____ML unit _________ volume ____ML
Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening Anti body screening CC DCT ABO/Rh B cell A1 cell Anti-D Anti-AB Anti- B Anti- A Patient sample
Sc3 Sc3 Sc3 Sc3 Sc2 Sc2 Sc2 Sc2 Sc1 Sc1 Sc1 Sc1 CC DCT ABO/Rh B cell A1 cell Anti-D Anti-AB Anti- B Anti- A Patient sample
CC AG 37 RT CC AG 37 RT CC AG 37 RT CC DCT ABO/Rh B cell A1 cell Anti-D Anti-AB Anti- B Anti- A Patient sample
Pre transfusion sample
Immediate post transfusion sample
2nd post transfusion sample ( if possible )
Elution result___________________________________
________________________________________ Antibody
identification __________________________________
__________________________________
Interp cross match cross match cross match cross match Cross matching
Interp CC AHG 37 IS Pre transfusion sample and unit number___________________
Pre transfusion sample and unit number___________________
Post transfusion sample and unit number___________________
post transfusion sample and unit number___________________
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ALTERNATIVES TO BLOOD TRANSFUSION

• CRYSTALLOID SOLUTIONS
• COLLOID SLOUTIONS
• DRUGS DDAVP
• BLOOD SUBSTITUTES EPO

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AUTOLOGUS BLOOD TRANSFUSION

• 1- Preoperative Collection (PAD)
• 2-Acute normovolemic haemodilution (ANH).
• 3- Red Cell salvage

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Table 1. Autologous Blood Donation  
Disadvantages Advantages
  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.    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 Jehovahs witnesses.   
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Nowing is not enough we must apply. Willing is
not enough we must do. Johann Von Goethe
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Thanks